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Anthem blue cross Rights and Obligations
No-Obligation Review Period
After you enroll in a Anthem blue cross health plan, you
will receive an Evidence of Coverage policy booklet that explains the
exact terms and conditions of coverage, including the plan's exclusions
and limitations. You have 10 full days to examine your plan's features.
During that time, if you are not fully satisfied, you may decline by
returning your Evidence of Coverage booklet along with a letter notifying
us that you wish to discontinue coverage. Evidence of Coverage booklets
are available for you to examine prior to enrolling. Ask your agent
or Anthem blue cross.
Guarding Your Privacy
Anthem blue cross is fully committed to protecting our members' privacy. Our
complete Notice of Privacy Practices provides a comprehensive overview
of the policies and practices we enforce to preserve our members' privacy
rights and control use of their health care information, including:
the right to authorize release of information; the right to limit access
to information; protection of oral, written and electronic information;
use of data; and information share with employers. You may obtain our
complete Notice of Privacy Practices from our Web site at http://www.bluecrossca.com.
You may also call the Customer Service number listed on your member
ID card, or prospective members may call 1-800-333-0912.
Requirement for Binding Arbitration
If you are applying for coverage, please note that Anthem blue cross requires
binding arbitration to settle all disputes, including claims of medical
malpractice. California Health and Safety Code Section 1363.1 and Insurance
Code Section 10123.19 require specified disclosures in this regard,
including the following notice: "It is understood that any dispute as
to medical malpractice, that is as to whether any medical services rendered
under this contract were unnecessary or unauthorized or were improperly,
negligently or incompetently rendered, will by California law, and not
by lawsuit or resort to court process except as California law provides
for judicial review of arbitration proceedings. Both parties to this
contract, by entering into it, are giving up their constitutional right
to have any such dispute decided in a court of law before a jury, and
instead are accepting the use of arbitration. Both parties also agree
to give up any right to pursue on a cal basis any claim or controversy
against the other.
Grievances
All complaints and disputes relating to your coverage must be resolved
in accordance with Anthem blue cross' grievance procedure. Grievances may be
made by telephone or in writing; the phone number and address are located
on your Anthem blue cross ID card. All grievances received by Anthem blue cross will
be answered in writing, together with a description of how Anthem blue cross
proposes to resolve the grievance.
Department of Managed Health Care
The California Department of Managed Care is responsible
for regulating health care service plans. If you have a grievance against
your health plan, you should first telephone your health plan at (800)
333-0912 and use your health plan's grievance process before contacting
the department. Utilizing this grievance procedure does not prohibit
any potential legal rights or remedies that may be available to you.
If you need help with a grievance that has not been satisfactorily resolved
by your health plan, or a grievance that has remained unresolved for
more than 30 days, you may call the department for assistance. You also
be eligible for an Independent Medical Review (IMR). If you are eligible
for an IMR, the IMR process will provide an impartial review of medical
decisions made by a health plan related to the medical necessity of
a proposed service or treatment, coverage decisions for treatments that
are experimental or investigational in nature and payment disputes for
emergency or urgent medical services. The department also has a toll-free
telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for
the hearing and speech impaired. The department's Internet Web site
(http://www.hmohelp.ca.gov) has complaint forms, IMR application forms
and instructions on-line.
Third-Party Liability
Anthem blue cross of California is entitled to reimbursement of benefits paid
if you recover damages from a legally liable third party. Examples of
third-party liability include car accidents and work-related injuries.
For complete information about third-party liability, refer to the plan
Evidence of Coverage booklet.
Loss Ratio
As required by law, we are advising you that Anthem blue cross of California's
incurred loss ratio for 2002 was 80.81 percent. This loss ratio was
calculated after provider discounts were applied.
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