Everyone seems to be talking about healthcare.

What are my rights?

As an HMO member, you have rights and responsibilities:

Member Rights:

  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 a 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.

Member Responsibilities:

  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 How do I choose/change my primary care physician?

Most people choose a physician at the time of open enrollment simply by noting the physician’s 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, please go to the Provider Directory page. Thank you for choosing a Santé provider for your family care.

How do I get access to care?

When accessing care at a physician’s office, ancillary provider, or a hospital facility, please identify yourself as a Santé 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 Santé Customer Service Representative at 559-228-5410. Ancillary Providers – When ancillary provider services are needed, your Santé 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 planned hospital.

How do you know if your plan provides coverage for the care your doctor wants to prescribe?

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.

Is there anyone I can call for help?

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.

What if I have an emergency?

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.

What if I need care after hours?

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.

What if I need care and I am out of the area?

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.


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