Rights & Responsibilities


Medicare Providers

It is imperative that you be aware of your rights and responsibilities as a participating provider with The Health Plan. You are expected to assist our members by making them aware of their rights and by supporting these within your practice. Please refer to Section 4 of the Provider Manual for important information regarding CMS quality standards that you are required to meet when caring for Medicare Advantage enrollees. Our Customer Service Department is available to assist you with any member issues that may arise at 1.877.847.7907.

Overview of Physician Responsibilities

Primary Care Physicians (PCPs): Act as a health care manager for members to arrange and coordinate their medical care, including but not limited to, routine care, and follow-up care after the receipt of emergency services.

Specialists: Provide continuity and coordination of care by sending a written report to PCPs regarding any treatment or consultation provided to members, regardless of whether the service was a result of a PCP referral or the member making his/her own arrangements.

All Contracted Physicians:

  • Arrange for the provision of medical services to The Health Plan members by a participating practitioner after-hours, on weekends, vacations, and holidays. Services from non-participating practitioners may not be covered, unless otherwise approved by The Health Plan.
  • Access for our members to all physician offices with 24-hour on-call capability, either directly or through an answering service, not an answering machine.
  • Assist members with their benefit coverage by getting written prior authorization for required services and prior auth to referring for out-of-plan services, as appropriate.
  • Facilitate candid discussion with members regarding appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage. Such discussions should include complete and current information concerning a diagnosis, treatment, and prognosis, in terms that the member (or designee) can be expected to understand.
  • Provide members the information necessary to give informed consent prior to the start of any procedure or treatment.
  • Maintain appropriate medical records regarding members and their treatment, recognizing that records are confidential and ensuring that they are maintained in accordance with legal and ethical requirements concerning confidentiality and security.
  • Cooperate with The Health Plan, or its designee, in the resolution of members' complaints, expedited appeals, appeals and/or grievances.
  • Comply with other administrative requirements as specified in the applicable contract or stipulated in the Provider Manual or its updates.
  • Promote the efficient delivery of medical services to maximize health care resources and the member's premium dollar and improve quality of care provided.
  • Refrain from providing treatment to the physician’s own family members.
  • Provide medical information in a culturally-competent manner to all members, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities.

NCQA Requirements:
Comply with The Health Plan medical records policy, quality assurance programs, medical management programs, and HEDIS® data collection.

CMS Marketing Guidelines:
Comply with CMS Marketing Guidelines for provider-based activities. The guidelines, available below, govern how providers can and cannot inform or educate patients about enrollment and plan information.

Medicaid Providers

Providers must inform enrollees of the costs for non-covered services prior to rendering such services. Providers are prohibited from collecting copays for missed appointments. Enrollees are held harmless for the costs of all Medicaid-covered services provided, except for any cost-sharing obligations. Providers are required to treat all information that is obtained through the performance of the services as confidential information to the extent that confidential treatment is provided under state and federal laws, rules, and regulations.

If you have any questions regarding a Medicaid member’s eligibility, please call Customer Service at 1.888.613.8385, Monday – Friday, 8:00 a.m. to 5:00 p.m. WV Medicaid determines eligibility for an enrollee to be on managed care.

The Health Plan encourages provider training to promote sensitivity to the special needs of this population. The Health Plan does not discriminate against providers acting within the scope of their license. Health care professionals, acting within the lawful scope of practice, are not prohibited or restricted from advising or advocating on behalf of an enrollee’s health status; medical care or treatment options (including any alternative treatment that may be self-administered); any information the enrollee needs for deciding among all relevant treatment options; or the risks, benefits, and consequences of treatment or no treatment.

The Health Plan may not make specific payments, directly or indirectly, to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to any particular enrollee. Indirect payments may include offerings of monetary value (such as stock options or waivers of debt) measured in the present or future.

We will provide information to members regarding their rights and responsibilities and any changes upon enrollment, annually, and at least 30 days prior to any change in their benefits.