Understanding My Health Plan

These are your rights as a health plan member.

• You can easily get information about the organization, its services, its practitioners and providers.
• You can easily get information about your member rights and responsibilities.
• We will treat you with respect. We will recognize your dignity and right to privacy.
• You can work with your healthcare provider to decide on treatments you need.
• You can talk honestly about the treatments that are right for your conditions, regardless of cost or benefit coverage.
• You can make complaints or appeals about us or the care or service we provide.
• You can recommend changes to our member rights and responsibilities policy.
• You can choose your healthcare providers.
• We will keep things you tell us about your health plan claims and other related information private.
• Your healthcare and healthcare coverage information will stay protected.
• You can review and get copies of your personal information on file.
• You can get screening and stabilization emergency services when and where you need them. You do not need prior authorization, regardless of cost or benefits coverage. This applies if severe pain, injury, or sudden illness convinces you that your health is at great risk.
• You can continue to get care from your specialty provider for up to 90 days or until you complete your care. This applies if you are getting treatment for a chronic or disabling condition. It applies if you are in your second or third trimester of pregnancy. It applies when you involuntarily change your healthcare plan. It applies if your provider leaves the network for any reason other than cause.

These are your responsibilities as a health plan member.

• Give as much of the information as you can that LifeWise and its providers need in order to provide care.
• Follow plans and instructions for care that you have agreed to with your providers.
• Try to understand your health problems.
• Work as much as possible with your healthcare providers to develop treatment goals you can agree on.
• Try to keep healthy habits, such as exercising, not smoking, and eating a healthy diet.
• Disclose relevant information. You must try to communicate clearly what you want and need.
• Avoid knowingly spreading disease.
• Understand your healthcare provider's obligation to provide care equally and efficiently to other patients and the community.
• Learn about your health plan coverage and options, including all covered benefits, limitations and exclusions, and rules about the use of information.
• Understand how to appeal coverage decisions.
• Show respect for other patients, health workers, and health plan employees.
• Make a good-faith effort to meet financial obligations.
• Follow the administrative and operational procedures of your health plan and healthcare providers.
• Report wrongdoing and fraud.

When you receive care from providers in the network, they will process your claims directly with us, so you don't need to handle any paperwork. However, if you receive care from a non-network provider, you may have to pay the provider for the service and then file a claim with us for reimbursement.

To file a claim for reimbursement, simply follow these steps:

• Complete and sign the form.
• Staple an itemized bill from the provider for the covered service.
• Mail your claim to the address shown on the form.

Please see your Benefit Booklet for more details on filing claims.

Request a Claim Review

If you disagree with how a claim was paid ─ as described on your Explanation of Benefits (EOB) ─ you can request a review. We must receive your request to review a claim within 180 days after you receive your EOB. You can either call Customer Service or submit a written request. If you suspect that payments were made for services you didn't receive - please call the Anti-Fraud Hotline at 800-596-3440.

Submit a Written Request

If you prefer, you can submit a written request so you can make a copy for your records. Along with your written request, include a copy of your EOB to identify details of the disputed claim and any other documents or information that may help resolve your claim to your satisfaction. After we receive your request, we'll send you detailed information about our appeals process, including the timeframes for each step of the process. Send your request to:

LifeWise Health Plan or Oregon
Attn: Claims
P.O. Box 91059
Seattle, WA 98111-9159

Questions? Concerns?
Please contact Customer Service.

Please note: Some groups may have a different contact phone number. Please confirm your contact number on the back of your ID card before calling. For more detailed information about your benefits, see your contract or Contact Us.

You can make complaints about:

• The care or service we provide
• The quality or availability of a healthcare service
• The care or service you get from any providers in our network.

You also have the right to appeal any action we take or decision we make about your coverage or services.

Learn what an Explanation of Benefits (EOB) is and how to read it.