Member Rights & Responsibilities
Medical Associates posts its member rights and responsibilities, as shown below. Questions may be directed to our Member Services Department, 563-584-4885 or 1-866-821-1365.
You have the Right:
You are expected:
Chain of Communication
The development and revision of members’ rights and responsibilities will be the responsibility of Medical Associates Health Plans. Any changes will reflect the input and guidance of the Quality Improvement Committee and/or Clinic Board of Directors.
The Quality Improvement Committee will be responsible for review and approval of member rights and responsibilities.
Upon approval by the Quality Improvement Committee, rights and responsibilities will be sent to the Medical Associates Clinic Board of Directors for review and approval.
If recommendations or revisions are deemed necessary by the Board of Directors, these will be channeled through the Quality Improvement Committee.
Utilization Management…Ensuring Appropriate Care
A health plan’s Utilization Management (UM) program works to ensure that the most appropriate and cost effective resources are utilized in the delivery of health care. A sound UM process provides members with clearly defined benefits review, authorization of coverage, guidance on available sources for in-network care, protocols for out-of-area care, and a step-by-step procedure for the appeal of denied coverage.
Medical Associates Health Plans is committed to providing quality care. We base our UM decisions solely on appropriateness of care and service and existence of coverage, because we believe that quality is achieved through an intricate balance of cost and utilization.
Please be reassured that we do not reward practitioners (or other individuals conducting utilization review) for issuing denials of coverage or services. At times during the decision making process (such as in the denial and appeal process), we may call upon board certified physicians with the same/similar expertise to be part of the decision making. None of these physicians, nor any staff, receive compensation for issuing or upholding denials.
Financial incentives for UM decision makers do not encourage decisions that result in under-utilization. To ensure this, we continuously monitor all forms of utilization data.
UM Criteria are Available. If you wish to have a copy of the criteria that is followed during the UM decision making process, please feel free to call our Health Care Services Department at 563-584-3275 or 1-800-325-7442, and we will provide a copy to you.
External Review Process. Medical Associates Health Plans complies with regulations that address external appeal. Some denials, after they exhaust our internal appeal processes, may be eligible for review by an Independent Review Organization (IRO). For most of our plans, the denial of coverage must be based on medical necessity to be eligible for external review. If you would like more information on the external appeal process, please contact Laura Boge, Member Services Manager, at 563-584-4857 or 1-800-747-8900.
Physician Reviewers are Available. If you wish to speak with a physician reviewer regarding a UM decision, including behavioral health cases, please call our Health Care Services Department at 563-584-3275 or 1-800-325-7442, and we will help you arrange for this.
Communication between Practitioners and Members
Medical Associates Health Plans is a medical delivery system comprised of over 40,000 members, a large network of dedicated health care providers and nursing professionals, and a full service operations team located in Dubuque, IA.
We are deeply committed to the satisfaction of our enrollees, with the belief that each member should be treated as an individual. Our expert caregivers combine their wisdom, knowledge, and resources to deliver the most compassionate, quality care possible.
An important aspect of efficient, quality care is open discussion. Our participating practitioners are encouraged to freely communicate with members about treatment options regardless of any benefit coverage limitation.
We believe it is essential for healthcare providers to talk openly with members regarding medical care sought, the risks, benefits, and consequences of treatment (or non-treatment), the option to refuse treatment, and the opportunity to express preferences about future care.
A collaborative and communicative partnership between healthcare provider and patient is an important goal of our health plan.