Mercy Care rights and responsibilities

Mercy Care DCS CHP

Mercy Care DCS CHP members and caregivers have the right to be treated with respect and consideration when they’re getting the health care services they need and deserve. 

Federal and State laws

Mercy Care DCS CHP complies with all Federal and State laws, including: 

• Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 80, 
• The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91, 
• The Rehabilitation Act of 1973, 
• Title IX of the Education Amendments of 1972 (regarding education programs and activities), 
• Titles II and III of the Americans with Disabilities Act; and 
• Section 1557 of the Patient Protection and Affordable Care Act. 

Member and caregiver rights 

You (members and caregivers) have the right to: 

• Receive information about Mercy Care DCS CHP, the services Mercy Care DCS CHP provides, the Mercy Care DCS CHP provider network and the Mercy Care DCS CHP provider directory at no charge. 
• File a complaint to Mercy Care DCS CHP about inadequate Notice of Adverse Benefit Determination letters or any aspect of Mercy Care DCS CHP’s service. 
• File a complaint with AHCCCS, Division of Health Care Management, Medical Management Unit at medicalmanagement@azahcccs.gov, if Mercy Care DCS CHP does not resolve the complaints about the Notice of Adverse Benefit Determination Letter to the member’s satisfaction. 
• Request information on the structure and operation of Mercy Care DCS CHP or Mercy Care DCS CHP’s contractors or subcontractors (42 CFR 438.10(g)(3)(i)). 
• Request information regarding if Mercy Care DCS CHP has physician incentive plans that affect referral from doctors. 
• Know about the type of compensation arrangements with providers, whether stop-loss insurance is required of providers and the right to review member survey results. 
• Not be discriminated against in the delivery of health care services based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. 

Confidentiality and confidentiality limitations

You have the right to:

• Privacy and confidentiality of your health care information. 
• Talk to health care professionals privately. 
• Get a copy of the “Privacy Rights” notice in your welcome packet. The notice has information on ways Mercy Care uses your records, which includes information on your health plan activities and payments for services. Your health care information will be kept private and confidential. It will be given out only with your permission or if the law allows it. 
• Know about health care privacy.
   
  • There are laws about who can see your medical and behavioral health information with or without your permission. Substance use treatment and communicable disease information (for example, HIV/AIDS information) cannot be shared with others without your written permission. 
  • There may be times that you want to share your medical or behavioral health information with other agencies or certain individuals who may be assisting you. In these cases, you can sign an Authorization for the Release of Information (ROI) Form, which states that your medical records, or certain limited portions of your medical records, may be released to the individuals or agencies that you name on the form. For more information about the Authorization for the Release of Information Form, contact Mercy Care at 602-212-4983 or 1-833-711-0776 (TTY 711). 
• Know about limits to confidentiality. There are times when we cannot keep information confidential. The law doesn’t protect the following information:
   
  • If you commit a crime or threaten to commit a crime at the provider’s office or clinic or against any person who works there, the provider must call the police. 
  • If you’re going to hurt another person, we must let that person know so that he or she can protect himself or herself. We must also call the police. 
  • We must also report suspected child abuse to local authorities. 
  • If there is a danger that you might hurt yourself, we must try to protect you. If this happens, we may need to talk to other people in your life or other service providers (e.g., hospitals and other counselors) to protect you. We’ll only share information necessary to keep you safe. 
• Know the other times when providers can share certain health information with family members and others involved in your care. For example, if:
   
  • You verbally agree to share the information.
  • You have an opportunity to object to sharing information, but don’t object. For example, if you allow someone to come into an exam room during an appointment, the provider can assume that you don’t object to sharing information during that visit.
  • It’s an emergency, or you don’t have the capacity to make health care decisions, and the provider believes disclosing information is in your best interest.
  • The provider believes you’re a serious and imminent threat to your health or safety, or someone else’s health and safety.
  • The provider uses the information to notify a family member of the member’s location, general condition or death.
  • The provider is following other laws requiring they share information.
• Know the other times when your information is shared without first getting your written permission to help arrange and pay for your care. These times could include the sharing of information with:
   
  • Physicians and other agencies providing health, social, or welfare services 
  • Your medical primary care provider 
  • Certain state agencies and schools following the law, involved in the child’s care and treatment, as needed 
  • Members of the clinical team involved in the child’s care 
• Know the other times when it may be helpful to share your behavioral health information with other agencies, such as schools or state agencies. This is done within the limits of the applicable regulations. The written permission may be required by your DCS Specialist before your information is shared.

Other rights

You also have the right to:

• Get services provided in a culturally competent manner, with consideration for members with limited English proficiency or reading skills, and those with diverse cultural and ethnic backgrounds as well as members with visual or auditory limitation at no cost.
• Choose a primary care provider (PCP) and primary dental provider (PDP) within the limits of the provider network, and choose other providers as needed from among those affiliated with the network; this also includes the right to refuse care from specified providers. 
• Know about providers who speak languages other than English. 
• Get a second opinion from a qualified health care professional registered with AHCCCS at no cost to the member.
• Receive information on available treatment options and alternatives, in a manner appropriate to the member’s condition and ability to understand. 
• Review his/her medical records in accordance with applicable State and Federal laws. 
• Request annually and receive at no cost a copy of his/her medical records as specified in 45 CFR 164.524. The member’s right of access to inspect and get a copy of his/her medical records may be denied if the information is: 
  
  
  • Psychotherapy notes; 
  • Information compiled for, or in reasonable anticipation of, a civil, criminal or administrative action; or 
  • Protected health information that is subject to the Federal Clinical Laboratory Improvements Amendments of 1988, or exempt pursuant to 42 CFR 493.3(a)(2). An individual may be denied access to read or receive a copy of medical record information without an opportunity for review in accordance with 45 CFR Part 164 (above) if:
     
    
    • The information meets the criteria stated above; 
    • The provider is a correctional institution or acting under the direction of a correctional institution as defined in 45 CFR 164.501; 
    • The information is obtained during the course of current research that includes treatment and the member agreed to suspend access to the information during the course of research when consenting to participate in the research; 
    • The information was compiled during a review of quality of care for the purpose of improving the overall provision of care and services; 
    • The denial of access meets the requirements of the Privacy Act, 5 U.S.C. 552a; or The information was obtained from someone other than a health care provider under the protection of confidentiality, and access would be reasonably likely to reveal the source of the information. 
• Seek review if access to inspect or request for a copy of medical record information is denied when:
   
  • A licensed health care professional has determined the access requested would reasonably be likely to endanger the life or physical safety of the member or another person; or 
  • The protected health information refers to another person and access would reasonably be likely to cause substantial harm to the member or another person. Mercy Care DCS CHP must respond within 30 days to the member’s request for a copy of the records, the response may be the copy of the record or, if necessary to deny the request, the written denial must include the basis for the denial and written information about how to seek review of the denial in accordance with 45 CFR Part 164. 
• Amend or correct his/her medical records as specified in 45 CFR 164.526 (Mercy Care DCS CHP may require the request be made in writing).
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. 
• Get information on beneficiary and plan information. 
• Receive treatment with respect and with recognition of the member’s dignity and need for privacy; the right to privacy includes protection of any identifying information except when otherwise required or permitted by law. 
• Participate in decisions regarding his or her health care, including the right to refuse treatment (42 CFR 438.100), and/or have a representative facilitate care or treatment decisions when the member is unable to do so. 
• Receive information, in a language and format that the member understands, about member rights and responsibilities, the amount, duration and scope of all services and benefits, service providers, services included and excluded as a condition of enrollment, and other information including: 
  
  
  • Provisions for after-hours and emergency health care services, which includes the right to access emergency health care services from a provider without prior authorization, consistent with the member’s determination of the need for such services as prudent; 
  • Information about available treatment options (including the option of no treatment) or alternative courses of care; 
  • Procedures for getting services, including authorization requirements and any special procedures for getting mental health and substance use services, or referrals for specialty services not furnished by the member’s PCP; 
  • Procedures for getting services outside the Mercy Care DCS CHP provider network;
  • Provisions for getting AHCCCS covered services that are not offered or available through Mercy Care DCS CHP, and notice of the right to obtain family planning services from an appropriate AHCCCS registered provider, and 
  • A description of how Mercy Care DCS CHP evaluates new technology for inclusion as a covered benefit.
• Use any hospital or other setting for emergency care [42 CFR 457.1207, 42 CFR 438.10].
• See the criteria used as a basis for decisions.
• Receive information regarding grievances, appeals and requests for a hearing about Mercy Care DCS CHP or the care provided. 
• Request a state fair hearing after Mercy Care DCS CHP has made an adverse determination 
• File grievances and appeals. 
• Receive help filing grievances and appeals. 
• Call Member Services if there are any questions regarding member rights. 

Mercy Care Long Term Care 

As a Mercy Care member, you have rights and responsibilities. These rights are listed below. It is important you read and understand each one. If you have questions, please ask your case manager. 

Your rights as a member 

You have the right to: 

• Exercise your rights. Exercising those rights shall not adversely affect service delivery to you.  
• Know the name of your PCP and/or case manager.  
• Get a copy of the Mercy Care Member Handbook, which includes a description of covered services.  
• Get information about how Mercy Care provides for after-hours and emergency care.  
• File a complaint about Mercy Care or its subcontractors.  
• Request information on the structure and operations of Mercy Care or its subcontractors.  
• Request information about how Mercy Care pays providers, controls costs and uses services. This information includes whether or not Mercy Care has a Physician Incentive Plan (PIP) and a description of the PIP.  
• Know whether stop-loss insurance is required.  
• Receive general grievance results and a summary of member survey results.  
• Know your costs to get services/treatments that are not covered by Mercy Care.  
• Receive information about how to get services, including services requiring authorization.  
• Receive information on how Mercy Care evaluates new technology to include as a covered service.  
• Receive information about changes to your services or what actions to take when your PCP leaves Mercy Care.  
• Receive fair treatment and get covered services without concern about race, ethnicity, national origin (to include those with limited English proficiency), ancestry, marital status, religion, gender, age, mental or physical disability, sexual orientation, genetic information, your ability to pay, or ability to speak English.  
• Receive information about how medical decisions can be made for you when you are not able to make them.  

Confidentiality and confidentiality limitations  

You have the right to: 

• Privacy and confidentiality of your health care information. 
• Talk to health care professionals privately. 
• Know our privacy practices. You will find a copy of the “Privacy Rights” notice in your welcome letter. The notice has information on ways in which Mercy Care uses your records, including information on your health plan activities and payments for services. Your health care information is kept private and confidential. It is given out only with your permission or if the law allows it.  
• Know about health care privacy. (See the “Health plan Notices of Privacy Practices” section.) 
• Know about limits to confidentiality. There are times when we cannot keep information confidential. The law doesn’t protect the following information:
    
  
  • If you commit a crime or threaten to commit a crime at the provider’s office or clinic or against any person who works there, the provider must call the police.  
    
  • If you’re going to hurt another person, we must let that person know so that he or she can protect himself or herself. We must also call the police.  
  • We must also report suspected child abuse to local authorities.  
  • If there is a danger that you might hurt yourself, we must try to protect you. If this happens, we may need to talk to other people in your life or other service providers (e.g., hospitals and other counselors) to protect you. We’ll only share information necessary to keep you safe.  
• Know the other times when providers can share certain health information with family members and others involved in your care. For example, if:
    
  • You verbally agree to share the information. 
  • You have an opportunity to object to sharing information, but don’t object. For example, if you allow someone to come into an exam room during an appointment, the provider can assume that you don’t object to sharing information during that visit. 
  • It’s an emergency, or you don’t have the capacity to make health care decisions, and the provider believes disclosing information is in your best interest. 
  • The provider believes you’re a serious and imminent threat to your health or safety, or someone else’s health and safety. 
  • The provider uses the information to notify a family member of the member’s location, general condition or death. 
  • The provider is following other laws requiring they share information.  
• Know the other times when your information is shared without first getting your written permission to help arrange and pay for your care. These times could include the sharing of information with:  
  • Physicians and other agencies providing health, social, or welfare services 
  • Your medical primary care provider 
  • Certain state agencies and schools following the law, involved in your care and treatment, as needed 
  • Members of the clinical team involved in your care  
• Know the other times when it may be helpful to share your behavioral health information with other agencies, such as schools or state agencies. This is done within the limits of the applicable regulations. Your written permission may be required before your information is shared.  
• Get a second opinion from a qualified health care professional within the network or have a second opinion arranged outside of the network at no cost to you if there are no other in network options. For more information, you can call Mercy Care at 602-263-3000 or 1-800-624-3879 (TTY 711).  
• Receive information on treatment options and alternatives, appropriate to your condition, in a way that you are able to understand. It should also be shared with you in a way that allows you to participate in decisions about your health care.  
• Know about advance directives.  
• Prepare an advance directive and know how to have medical decisions made for you if you are not able to make them for yourself.  

Treatment decisions 

You have the right to: 

• Agree to, or refuse, treatment and to choose other treatment options available to you.  
• Get information on how to get services and authorizations for services. 
• Choose a Mercy Care PCP to plan your health care. 
• Change your PCP.  
• Within the limits of applicable regulations, Mercy Care staff may help manage your health care by working with you, community and state agencies, schools, and your doctor. 
• Talk with your PCP to get complete and current information about your health care and condition. This information helps you and/or your family understand your condition and be a part of making decisions about your health care.  
• Get information about which medical procedures you will have and who will 
  perform them. 
• Get a second opinion within the Mercy Care network. You can request a second opinion from a doctor outside of Mercy Care’s network, at no cost to you only if there is not adequate in network coverage.  
• Refuse care from a doctor to whom you were referred, and you can ask for a different doctor.  
• Choose someone to be with you for treatments and exams. 
• Have a female in the room for breast and pelvic exams. 
• Know treatment choices or types of care available to you and the benefits and/or drawbacks of each choice. You have the right to have treatment choices presented to you in a way that you can understand. 
• Develop a plan with your caregiver provider agency to decide your preferences when your caregiver is late or does not show up. 
• Develop a plan with your caregiver provider agency to decide your preferences for each service provided when a service is short. 
• Say, “no” to treatments, services and PCPs. You have the right to be informed about what may happen by not having the treatment. Your eligibility or medical care does not depend on your agreement to follow a treatment plan. 
• Say, “no” to tasks that a provider may ask you to perform that are not part of your care plan. 
• Say, “no” to medications or restraints, except for times when your doctor thinks these actions are needed to protect you or others from harm. 
• Transfer or leave a long-term services and supports home because of medical reasons, for your own good or the good of others, or for not paying.  

Your rights under the Home and Community Based Services (HCBS) Rules  

Mercy Care works to ensure that all staff and providers work in a manner consistent with a person-centered approach that respects and enhances a member’s right of choice, integration and autonomy. 

You have the right to:   

• Privacy, dignity and respect, and freedom from coercion and restraint.  
• Make requests in the way your services and supports are delivered.  
• Reside in the least restrictive setting.  
• Actively engage and participate in your community.  
• Get information about creating advance directives. Advance directives tell others how to make medical decisions for you if you are not able to make them for yourself. 

Medical records requests  

• At no cost to you, you have the right to annually request and receive one copy of your medical records and/or inspect your medical records. You may not be able to get a copy of medical records if the record includes any of the following information: psychotherapy notes put together for a civil, criminal or administrative action; protected health information that is subject to the Federal Clinical Laboratory Improvements Amendments of 1988; or protected health information that is exempt due to federal codes of regulation.  
• Mercy Care will reply to your request within 30 days. Mercy Care’s reply will include a copy of the requested record or a letter denying the request. The written denial letter will include the basis for the denial and information on ways to get the denial reviewed.  
• You have the right to request an amendment to your medical records. Mercy Care may ask that you put this request in writing. If the amendment is made, whole or in part, we will take all steps necessary to do this in a timely manner and let you know about changes that are made.  
• Mercy Care has the right to deny your request to amend your medical records. If the request is denied, whole or in part, then Mercy Care will provide you with a written denial within 60 days. The written denial includes the basis for the denial, notification of your right to submit a written statement disagreeing with the denial and how to file the statement.  

Reporting your concerns  

You have the right to: 

• Tell Mercy Care about any complaints or issues you have with your health care services. 
• File an appeal with Mercy Care and get a decision in a reasonable amount of time. 
• Give Mercy Care suggestions about changes to policies and services.  
• Report your concerns about Mercy Care.  

Personal rights  

You have the right to: 

• Choose to share a room with your spouse when appropriate if you live in a nursing facility or an alternative residential facility.  
• Remain in your home if you choose.  
• Manage your own money or choose someone you trust to manage your money on your behalf.  
• Use your rights as a citizen.  
• Choose to speak or not to speak with people.  
• Keep and use your personal clothing and belongings when there is space and no medical reasons not to if you live in a nursing facility or an alternative residential facility. 
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.  
• Receive information on beneficiary and plan information.  

Respect and dignity  

You have the right to: 

• Receive treatment with respect and with due consideration for your dignity and privacy. 
• Participate in decisions regarding your health care, including the right to refuse treatment. 
• Get quality medical services that support your personal beliefs, medical condition and background in a language you understand. You have the right to know about other providers who speak languages other than English. 
• Get interpretation services if you do not speak English. Sign language services are available if you are deaf or have difficulty hearing. You may ask for materials in other formats or languages from Mercy Care Member Services. 
• Get materials in alternative formats (such as large type or audio recording) or in another language.  
• Get notice in writing when any of your health care services are reduced, suspended, terminated or denied. You must follow the instructions in your notification letter. 
• Get the type of information about your treatment that is available to you in a way that helps your understanding given your medical condition.  

Emergency care and specialty services  

You have the right to: 

• Get emergency health care services without the approval of your PCP or Mercy Care when you have a medical emergency. You may go to any hospital emergency room or other setting for emergency care.  
• Get behavioral health services without the approval of your PCP or Mercy Care.  
• See a specialist with a referral from your PCP.  
• Refuse care from a doctor to whom you were referred, and you can ask for a different doctor.  
• Request a second opinion from another Mercy Care doctor.  

Mercy Care Developmental Disabilities 

As a Mercy Care member, you have rights and responsibilities. These rights are listed below. It is important that you read and understand each one. If you have questions, please call Mercy Care Member Services. 

Your rights as a member 

You have the right to exercise your rights. Exercising those rights shall not adversely affect service delivery to you. You have the right to:  

• Know the name of your PCP and/or case manager. 
• Get a copy of the Mercy Care Member Handbook, which includes a description of covered services.  
• Get information about how Mercy Care provides after-hours and emergency care. 
• File a complaint about Mercy Care or its subcontractors. 
• Request information about the structure and operations of Mercy Care or their subcontractors.  
• Get information about how Mercy Care pays providers, controls costs and uses services. This information includes whether or not Mercy Care has Physician Incentive Plans (PIP) and a description of the PIP.  
• Know whether stop loss insurance is required. 
• Know general grievance results and a summary of member survey results. 
• Get information about your costs to get services or treatments that are not covered by Mercy Care.  
• Get information about how to get services, including services requiring authorization. 
• Get information about how Mercy Care evaluates new technology to include as a covered service.  
• Get information about changes to your services or what actions to take when your PCP leaves Mercy Care.  
• Get fair treatment and covered services without concern about race, ethnicity, national origin (to include those with limited English proficiency), religion, gender, age, mental or physical disability, sexual orientation, genetic information, ability to pay, or ability to speak English.  
• Get information about how medical decisions can be made for you when you are not able to make them.  

Confidentiality and confidentiality limitations  

You have the right to: 

• Privacy and confidentiality of your health care information. 
• Talk to health care professionals privately. 
• Get a copy of the “Privacy Rights” notice in your welcome packet. The notice has information on ways Mercy Care uses your records, which includes information on your health plan activities and payments for services. Your health care information will be kept private and confidential. It will be given out only with your permission or if the law allows it.  
• Know about health care privacy. (See the “Health plan Notices of Privacy Practices” section.)  
• Know about limits to confidentiality. There are times when we cannot keep information confidential. The law doesn’t protect the following information: 
   
  • If you commit a crime or threaten to commit a crime at the provider’s office or clinic or against any person who works there, the provider must call the police.  
  • If you’re going to hurt another person, we must let that person know so that he or she can protect himself or herself. We must also call the police.  
  • We must also report suspected child abuse to local authorities.  
  • If there is a danger that you might hurt yourself, we must try to protect you. If this happens, we may need to talk to other people in your life or other service providers (e.g., hospitals and other counselors) to protect you. We’ll only share information necessary to keep you safe. 
• Know the other times when providers can share certain health information with family members and others involved in your care. For example, if:
   
  • You verbally agree to share the information. 
  • You have an opportunity to object to sharing information, but don’t object. For example, if you allow someone to come into an exam room during an appointment, the provider can assume that you don’t object to sharing information during that visit. 
  • It’s an emergency, or you don’t have the capacity to make health care decisions, and the provider believes disclosing information is in your best interest. 
  • The provider believes you’re a serious and imminent threat to your health or safety, or someone else’s health and safety. 
  • The provider uses the information to notify a family member of the member’s location, general condition or death. 
  • The provider is following other laws requiring they share information.  
• Know the other times when your information is shared without first getting your written permission to help arrange and pay for your care. These times could include the sharing of information with:
    
  • Physicians and other agencies providing health, social, or welfare services 
  • Your medical primary care provider 
  • Certain state agencies and schools following the law, involved in your care and treatment, as needed 
  • Members of the clinical team involved in your care  
• Know the other times when it may be helpful to share your behavioral health information with other agencies, such as schools or state agencies. This is done within the limits of the applicable regulations. Your written permission may be required before your information is shared. 
• Get a second opinion from a qualified health care professional within the network or have a second opinion arranged outside of the network at no cost to you if there are no other in network options. For more information, you can call Mercy Care at 602-263-3000 or 1-800-624-3879 (TTY 711).  
• Receive information on treatment options and alternatives, appropriate to your condition, in a way that you are able to understand. It should also be shared with you in a way that allows you to participate in decisions about your health care.  
• Know about advance directives.  
• Prepare an advance directive and know how to have medical decisions made for you if you are not able to make them for yourself.  

Treatment decisions 

You have the right to:   

• Agree to, or refuse, treatment and to choose other treatment options available to you. You can get this information in a way that helps your understanding and is appropriate to your medical condition.  
• Choose a Mercy Care PCP to coordinate your health care.  
• Change your PCP.  
• Talk with your PCP to get complete and current information about your health care and condition. This will help you and/or your family understand your condition and be a part of making decisions about your health care.  
• Within the limits of applicable regulations, Mercy Care staff may help manage your health care by working with you, community and state agencies, schools, and your doctor. 
• Get information about which medical procedures you will have and who will perform them.  
• Get a second opinion from a qualified health care professional within the network.  
• Get a second opinion arranged outside of the network, at no cost to you, only if there is not adequate in network coverage.  
• Know treatment choices or types of care available to you and the benefits and/or drawbacks of each choice.  
• Have treatment choices presented to you in a way that you can understand.  
• Refuse care from a doctor to whom you were referred, and you can ask for a different doctor.  
• Choose someone to be with you for treatments and exams.  
• Have a female in the room for breast and pelvic exams.  
• Say “no” to treatment, services or PCPs. Your eligibility or medical care does not depend on your agreement to follow a treatment plan. You will be informed about what may happen to your health if you do not have the treatment.  
• Receive notice from us in writing when any health care services requested by your PCP are reduced, suspended, terminated or denied. You must follow the instructions in the notification letter sent to you.  

Members who are part of Division of Developmental Disabilities  

• You have the right to develop a plan with their caregiver provider agency to decide your preferences when your caregiver is late or does not show up.  

Your rights under the Home and Community Based Services (HCBS) Rules  

Mercy Care works to ensure that all staff and providers work in a manner consistent with a person-centered approach that respects and enhances a member’s right of choice, integration and autonomy. You have the right to: 

• Privacy, dignity and respect, and freedom from coercion and restraint.  
• Make requests in the way your services and supports are delivered.  
• Live in the least restrictive setting. 
• Actively engage and participate in your community.  

Advance directives  

• You have the right to be provided with information about creating advance directives. Advance directives tell others how to make medical decisions for you if you are not able to make them for yourself.  

Medical records requests  

• At no cost to you, you have the right to annually request and receive one copy of your medical records and/ or inspect your medical records. You may not be able to get a copy of medical records if the record includes any of the following information: psychotherapy notes put together for a civil, criminal or administrative action; protected health information that is subject to the Federal Clinical Laboratory Improvements Amendments of 1988; or protected health information that is exempt due to federal codes of regulation.  
• Mercy Care will reply to your request within 30 days. Mercy Care’s reply will include a copy of the requested record or a letter denying the request. The written denial letter will include the basis for the denial and information on ways to get the denial reviewed.  
• You have the right to request an amendment to your medical records. Mercy Care may ask that you put this request in writing. If the amendment is made, whole or in part, we will take all steps necessary to do this in a timely manner and let you know about changes that are made.  
• Mercy Care has the right to deny your request to amend your medical records. If the request is denied, whole or in part, then Mercy Care will provide you with a written denial within 60 days. The written denial includes the basis for the denial, notification of your right to submit a written statement disagreeing with the denial and how to file the statement.  

Reporting your concerns  

You have the right to: 

• Tell Mercy Care about any complaints or issues you have with your health care services. 
• File an appeal with Mercy Care and get a decision in a reasonable amount of time. 
• Give Mercy Care suggestions about changes to policies and services. 
• Complain about Mercy Care.  

Personal rights  

You have the right to: 

• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.  
• Receive information on beneficiary and plan information.  

Respect and dignity 

You have the right to:  

• Get treatment with respect and with due consideration for your dignity and privacy.  
• Participate in decisions regarding your health care, including the right to refuse treatment. 
• Get quality medical services that support your personal beliefs, medical condition and background. You can get these services in a language you understand. You have the right to know about other providers who speak languages other than English. 
• Get interpretation services if you do not speak English. Sign language services are available if you are deaf or have difficulty hearing. You may ask for materials in other formats or languages from Mercy Care Member Services. 
• Get the type of information about your treatment that is available to you in a way that helps your understanding given your medical condition.  

Emergency care and specialty services  

You have the right to:  

• Get emergency health care services without the approval of your PCP or Mercy Care when you have a medical emergency. You may go to any hospital emergency room or other setting for emergency care.  
• Get behavioral health services without the approval of your PCP or Mercy Care. 
• See a specialist with a referral from your PCP. 
• Refuse care from a doctor you were referred to, and you can ask for a different doctor. 
• Request a second opinion from another Mercy Care doctor. 

Mercy Care Advantage Member Rights and Responsibilities

As a member of Mercy Care Advantage, you have rights and responsibilities, and they are listed below. If you have any questions, please call Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711). We’re here for you 8 a.m. to 8 p.m., 7 days a week. You can find more details about your rights and responsibilities in the Mercy Care Advantage Evidence of Coverage.

Member Rights

• Be treated with respect for your privacy and dignity at all times.
• We must provide information in a way that works for you and consistent with your cultural sensitivities (in languages other than English, in braille, in large print, or other alternate formats).
• We must ensure that you get timely access to your covered services and drugs.
• We must protect the privacy and confidentiality of your personal health information.
• We must give you information about the plan, its network of providers, and your covered services.
• You have the right to know your treatment options and participate in decisions about your health care.
• You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself. This is called an “advance directive” and is very helpful when you can’t speak for yourself due to an accident or illness.
• You have the right to file a complaint about Mercy Care Advantage, our network providers, or any issues you are having with your plan coverage. 
• You have the right to file an appeal to ask us to reconsider decision we have made and get a decision in a reasonable amount of time. 
• You have rights if you believe you are being treated unfairly or your rights have been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, sexual orientation, or national origin, you can call:
  • The Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697 or call your local Office for Civil Rights. 
• If it is about something else that does not involve discrimination: 
  • Call our Member Services Department. 
  • Call the State Health Insurance Assistance Program (SHIP) at 1-800-432-4040. 
  • Or call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048).

Member Responsibilities

• Get familiar with your covered services and the rules you must follow to get these covered services. Use your Mercy Care Advantage Evidence of Coverage to learn what is covered for you and the rules you need to follow to get your covered services.
  
• If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us.
• Tell your doctor and other health care providers that you are enrolled in our plan.
• To give your doctor and other providers the information they need to care for you, and to follow the treatment plans and instructions that you and your doctors agree upon. Be sure to ask your doctors and other providers if you have any questions. 
• To be considerate and act in a way that supports the care given to other patients and helps your doctor’s office, hospitals, and pharmacies deliver covered services. 
• Pay what you owe. As a plan member, you are responsible for these payments:
  • You must continue to pay your Medicare premiums to remain a member of the plan. 
  • Pay your share of the cost when you get a covered drug or services.  
• Notify us when your address or phone number changes so we can keep your membership record up to date and know how to contact you. 
• Mercy Care Advantage has an approved plan service area. You can travel outside our plan service area for up to six months, but your plan coverage will be limited to urgent and emergent services. Please call our Member Services Department who can explain  plan coverage when traveling outside our approved plan service area.  
• If you permanently move outside of our Mercy Care Advantage approved plan service area, please notify us immediately with your new address.  You will be unable to remain enrolled in our plan and will need to complete the following actions: 
  • Update your address with Social Security (or the Railroad Retirement Board). Social Security will notify Medicare of your new address.  
  • Enroll in a Medicare health plan in your new home service area.  You can get assistance locating Medicare health plans by calling the State Health Insurance Assistance Program (SHIP).
  • Using the Medicare Plan Finder tool available on Medicare.gov or by calling Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048).