Member rights and responsibilities
As a member of Fallon Health, you have certain rights and responsibilities.
Additional resources for answers to questions about:
- Your rights and responsibilities as a member of Fallon Health
- Care provided by a plan provider
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Member rights
As a Fallon Health member, you have the right to:
- Be informed about Fallon Health and covered services.
- Receive information about the managed care organization, its services, its practitioners and providers, and members’ rights and responsibilities.
- Be informed about how medical treatment decisions are made by the contracted medical group or Fallon Health, including payment structure.
- Choose a qualified contracted primary care physician and contracted hospital.
- Know the names and qualifications of physicians and health care professionals involved in your medical treatment.
- Receive information about an illness, the course of treatment and prospects for recovery in terms that you can understand.
- Actively participate in decisions regarding your own health and treatment options, including the right to refuse treatment.
- Receive a second opinion on a medical procedure from an in-plan provider and have Fallon pay for the second opinion consultation. Ask your Primary Care Physician to refer you to an in-network contracted provider for a second opinion consultation. Prior approval from Fallon is required when a second medical opinion is being requested to a provider who is not part of the Fallon provider network.
- Receive emergency services when you, as a prudent layperson acting reasonably, would have believed that an emergency medical condition existed.
- Candidly discuss appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage, presented by your provider in a manner appropriate to your condition and ability to understand.
- Be treated with dignity and respect, and to have your privacy recognized.
- Keep your personal health information private as protected under federal and state laws—including oral, written and electronic information across the organization. Unauthorized people do not see or change your records. You have the right to review and get a copy of certain personal health information (there may be a fee for photocopies).
- Make complaints and appeals without discrimination about the managed care organization or the care provided, and expect problems to be fairly examined and appropriately addressed.
- If your grievance involved an adverse determination, and you are not satisfied with our final decision, you have the right to file an external review.
- You may obtain the forms you need to file for an external review by calling the Department of Public Health Office of Patient Protection at 800-436-7757 or by accessing their website at http://www.mass.gov/anf/budget-taxes-and-procurement/oversight-agencies/health-policy-commission/patient-protection/.
- Federal employees may ask the United States Office of Personnel Management for an external review by writing to:
United States Office of Personnel Management
Insurance Services Programs, Health Insurance Group 3
1900 E. Street, NW
Washington, DC 20415-3630 - Exercise these rights regardless of your race, physical or mental ability, ethnicity, gender, sexual orientation, creed, age, religion or your national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for your care. Expect these rights to be upheld by both Fallon Health and its contracted providers.
- Make recommendations regarding Fallon Health’s members’ rights and responsibilities policies.
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Member responsibilities
As a Fallon Health member, you have the responsibility to:
- Provide, to the extent possible, information that Fallon Health, your physician or other care providers need in order to care for you.
- Do your part to improve your own health condition by following treatment plan, instruction and care that you have agreed on with your physician(s).
- Understand your health problems, and participate in developing new and existing, mutually agreed-upon treatment goals to the degree possible.
If you have any questions about your rights or responsibilities as a member of Fallon Health, please contact:
Fallon Health, Inc.
10 Chestnut St.
Worcester, MA 01608
800-868-5200
(TTY users please call TRS Relay 711)
www.fallonhealth.org
For questions regarding care provided by a plan physician, please contact:
Commonwealth of Massachusetts
Board of Registration in Medicine
560 Harrison Ave., Suite G-4
Boston, MA 02118
617-654-9800
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