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Member Rights & Responsibilities

As a Balance Member, you have rights as a healthcare consumer. To ensure everyone receives the care and treatment they deserve, you also have certain responsibilities.

All Balance Members have the right to:

  1. Courteous and considerate treatment; to be treated with respect and recognition of their dignity and right to privacy.
  2. Receive information about Balance, its services, its practitioners/providers, and members’ rights and responsibilities.
  3. Make recommendations regarding Balance’s member rights and responsibilities policy.
  4. Be informed about their available health plan benefits, including a clear explanation about how to obtain services.
  5. Receive appropriate preventive health services as indicated in their Evidence of Coverage (EOC).
  6. Receive upon request, names, specialties, and titles of the professionals responsible for their care.
  7. Amend their own health care information that Balance has when they consider it is incorrect or incomplete.
  8. Participate with practitioners in the decision-making regarding their health care.
  9. Inspect and copy their own medical information used to make decisions about their health care.
  10. Request a confidential or candid discussion with Balance’s qualified Medical Management staff regarding one’s health matter and appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
  11. Receive reasonable information regarding the risk for a given treatment, the length of disability, and the qualifications of the care provider prior to giving consent for any procedure.
  12. Additional medical or surgical opinions from out–of–network providers, in situations when your treating physician or the Plan feels this would be helpful in determining a diagnosis or course of treatment (with an approved referral).
  13. Opt-in or opt-out of participating in optional health plan activities.
  14. Be represented by parents, guardians, family members, or other conservators for those who are unable to fully participate in their treatment decisions.
  15. Be fully informed of Balance’s grievance procedure and how to use it without fear of prejudicial treatment from their health care provider.
  16. Voice complaints or appeals about Balance or the care provided.
  17. A timely response to requests for services, complaints, and inquiries regarding their health benefits and services.
  18. Request a copy of Balance’s Notice of Privacy Practices.

Members are responsible:

  1. For knowing and understanding their health benefits and services and how to obtain them.
  2. For contacting their physician or Balance coordinator with any questions or concerns regarding health benefits or services.
  3. To provide, to the extent possible, information that Balance and its practitioners/providers need in order to care for them.
  4. To understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
  5. For cooperating with those providing health care services; however, they have the right to refuse medical treatment.
  6. To follow the plans and instructions for care that they have agreed upon with their practitioners.
  7. To provide Balance with information when another source responsible to pay for health care is involved, such as liability insurance after an accident. In these cases, members have the responsibility to cooperate with their health plan for proper reimbursement of injury treatment by the other source to their health plan.