As an HMO member, you have rights and responsibilities:
1. The right to courteous and considerate treatment
2. The right to be treated with dignity and respect
3. The right to be informed about available health plan benefits, including a clear explanation about how to obtain service
4. The right to expect privacy and confidentiality regarding their medical and health conditions and their personal issues
5. The right to receive the appropriate preventive health services, as indicated in the Evidence of Coverage
6. The right to receive reasonable information regarding the risk for a given treatment, the length of disability and the qualifications of the provider of care - prior to giving consent for any procedure
7. The right to reasonable response to a request for medical services, including evaluations and referrals
8. The right to be fully informed of their HMO's grievance procedure and how to use it without fear of prejudicial treatment from their health provider
9. The right to a timely response to complaints and inquiries regarding their health benefits and services
10. The right to receive, upon request, the names, specialties, and titles of the professionals responsible for their care.
1. Members are responsible for cooperating with those providing health services; they have the right, however, to refuse medical treatment
2. Members are responsible for contacting their physician or HMO with any questions or concerns regarding their healthcare benefits or services
3. Members are responsible for being aware of their health benefits and services and how to correctly obtain them
4. Members are responsible for providing all information needed by the professional staff to care for the member
5. Members are responsible for following instructions and guidelines given by those providing health services
Most people choose a physician at the time of open enrollment simply by
noting the physicians name and provider number in their insurance form[ You
may also choose, or change, your PCP by calling the phone number listed on
the back of your HMO card. For assistance in choosing a physician go to How
to choose the right doctor or go to our Find a Doctor program to find a
doctor that meets your needs in your area. Thank you for choosing a SCP
provider for your family care.
When accessing care at a physician office, ancillary
provider or a hospital facility, please identify yourself as a Sante member
and present your insurance card at each visit. Please be prepared to pay any
required co-pays or fees at the time of service. Primary Care Physician (PCP
- Once selected, this physician will coordinate your healthcare services,
from preventive care, physical exams and routine health problems, to
specialists, emergency care and hospitalization. Your medical care is
available 24 hours a day, seven days a week. Specialist Physician - When
necessary, your PCP will establish a referral to a Specialist Physician to
meet additional, specialized medical needs Self-Referrals - OB and
Gynecological visits are considered self-referral and members may make an
appointment directly with a Sante OB-GYN office. Additional self-referral
benefits may apply to specific HMO plans for various medical services. Check
your benefit plan book or call your Sante Customer Service Representative at
559-228-5410. Ancillary Providers - When ancillary provider services are
needed, your Sante provider office will direct you to a contracted facility.
Examples of this are laboratory, x-ray or physical therapy providers.
Hospitals - When a non-emergent inpatient or outpatient hospitalization is
needed, your Sante provider will arrange for admittance to a plan hospital.
The best way is to contact your HMO, using the phone
number listed on the back of your insurance card. Knowing your benefits is
the responsibility of the patient.
Santé Customer Service (559) 228-5410. The Santé customer
service representative is your liaison to your health care needs. Call us
instead of your HMO plan for information or assistance with: General
Inquiries, such as fees and co-pay responsibilities Sante healthcare
providers Self-referral Complaints/Grievances Appeal Process Advanced
Directives - Living will or Durable Power of Attorney for healthcare.
When possible, you should call your PCP for urgent care
needs or before seeking emergency services. Your PCP can coordinate the
required medical assistance. If immediate emergency service is needed due to
sudden illness or injury that cannot be delayed without risk or permanent
damage to your health, you should call 911, or go directly to the nearest
hospital. Sante asks you attempt to contact your PCP immediately, if that is
not possible, please contact him or her within 48 hours of the emergency.
If non-emergent care is needed after your physician
office is closed, call your normal physician office number. An answering
service or recorded message will assist you. That provider, or another
provider serving as an "on-call" provider, will then contact you within a
reasonable amount of time.
Should emergent or urgent services be needed when you have traveled out of the Central California area, you should seek appropriate care, then contact your PCP or the Sante Customer Service Department at (559) 228-5410.