Your Rights & Responsibilities
The best place to learn about your rights as our member is to read the member handbook. It contains the information below and tells you about your rights to file complaints or appeals.
Have questions or need help? Please call Member Services at 1-800-600-4441 (TTY 711).
As an enrollee, you have a right to:
- Help make decisions about your health care, including mental and substance use disorder services and refusing treatment
- Be informed about all treatment options available, regardless of cost
- Change primary care providers
- Get a second opinion from another provider in your health plan
- Get services without having to wait too long
- Be treated with respect and dignity; Discrimination is not allowed — No one can be treated differently or unfairly because of his or her race, color, national origin, gender, sexual preference, age, religion, creed or disability.
- Speak freely about your health care and concerns without any bad results
- Have your privacy protected and information about your care kept confidential
- Ask for and get copies of your medical records
- Ask for and have corrections made to your medical records when needed
- Ask for and get information about:
- Your health care and covered services
- Your provider and how referrals are made to specialists and other providers
- How we pay your providers for your medical care
- All options for care and why you are getting certain kinds of care
- How to get help with filing a grievance or complaint about your care
- Our organizational structure including policies and procedures, practice guidelines and how to recommend changes
- Receive plan policies, benefits, services and Members’ Rights and Responsibilities at least yearly
- Receive a list of crisis phone numbers
- Receive help completing mental or medical advance directive forms
As an enrollee, you agree to:
- Help make decisions about your health care, including refusing treatment
- Keep appointments and be on time; Call your provider’s office if you are going to be late or if you have to cancel the appointment
- Give your providers information they need to be paid for providing services to you
- Bring your services card and health plan ID card to all of your appointments
- Learn about your health plan and what services are covered
- Use health care services when you need them
- Know your health problems and take part in agreed-upon treatment goals as much as possible
- Give your providers and Amerigroup complete information about your health
- Follow your provider’s instructions for care that you have agreed to
- Use health care services appropriately — If you do not, you may be enrolled in the Patient Review and Coordination Program. In this program, you are assigned to one primary care provider, one pharmacy, one prescriber for controlled substances and one hospital for non-emergency care. You must stay in the same plan for at least 12 months.
- Inform the Health Care Authority if your family size or situation changes, such as pregnancy, births, adoptions, address changes or you become eligible for Medicare or other insurance
- Renew your coverage annually using the Washington Health Benefit Exchange at Washington Health Plan Finder, and report changes to your account such as income, marital status, births, adoptions, address changes or becoming eligible for Medicare or other insurance
You have the right to file a complaint if you have a problem with:
- Our plan
- Your doctor, a behavioral health provider or any other plan provider
- Getting a bill from your provider
- Being sent to collections due to an unpaid medical bill
- The quality of your care or how you were treated
- Getting health care
How to file a complaint
You or a representative acting on your behalf can call or write to us. We’re happy to help you file your complaint. To file a complaint, either:
- Call us toll free at 1-800-600-4441 (TTY 711)
- Write to us at:
705 5th Ave S., Suite 300
Seattle, WA 98104
- The date the problem happened
- Who was involved
- As much information about the problem or event as you can (if it’s about a bill, send a copy of the bill)
When we get your complaintOur grievance coordinator will:
- Call or send you a letter within 2 business days to confirm we received your complaint
- Look into your grievance and address your concerns within 45 calendar days
If we can’t resolve your complaint, you can also file a grievance directly with the Health Care Authority by calling 1-800-562-3022 (TTY 711).
An appeal is when you ask us to reconsider a decision we made to deny or reduce care or services. This includes things like:
- Telling you we won’t pay for treatment or services
- Paying for less or fewer treatments or services
- Ending treatments or services early
How to file an appeal
You or an authorized representative, friend, family member or doctor can file an appeal. You must appeal within 60 calendar days of the date of the adverse benefit determination letter. An adverse benefit determination means the denial or limited authorization of a requested service. If you want to keep getting those services while we review the appeal, you must request an appeal within 10 calendar days. To have someone else appeal on your behalf, we’ll need your written consent.
You or your authorized representative can file an appeal by mail, fax or phone.
To file an appeal by mail, send a letter to:
705 5th Ave. S., Suite 300
Seattle, WA 98104
- To file an appeal by fax, send a letter to 1-844-759-5953
- To an appeal by phone, call 1-800-600-4441 (TTY 711).
- Your name, address, phone number and member ID number
- The date on your adverse benefit determination letter
- A description of the service or treatment that was denied or reduced
- The name, address and phone number of the doctor
- The reason you disagree
- Any evidence or documents that can help your argument
We’ll send you a letter within five calendar days telling you we received your appeal. In most cases, we’ll review and decide within 14 calendar days of receiving your appeal request. We must tell you if we need more time to make a decision, however the extension cannot delay the decision more than 28 calendar days after the request for an appeal.
If you keep getting a service during the appeal process and you lose the appeal, you may have to pay for the services you received.
If waiting the 14 calendar days could put your life or health in danger, you or your doctor can ask for an expedited (or fast) appeal. To ask for an expedited appeal, call and tell us why you need one. If we expedite your appeal, we’ll send you a decision within 3 calendar days of receiving your appeal.
If we deny your request for an expedited appeal, your appeal will be reviewed within the normal time. We’ll also call you right away to let you know. We’ll mail you our decision about the review timeline within two calendar days. If you don’t like our decision to change your request from an expedited appeal to a standard appeal, you may file a grievance.
You may also ask for an administrative hearing. This is when an administrative law judge who doesn’t work for us or the Health Care Authority reviews your appeal.
You have 120 calendar days from the date of our appeal decision to request an administrative hearing. If you want to keep getting denied services during your hearing, you only have 10 calendar days to ask for one.
You may ask for an administrative hearing by phone or mail:
- To ask for an administrative hearing by phone, call the Office of Administrative Hearings at 1-800-583-8271
- To ask for an administrative hearing by mail, write to:
Office of Administrative Hearings
P.O. Box 42489
Olympia, WA 98504-2489
Tell the Office of Administrative Hearings:
- Amerigroup is involved
- The reason for the hearing
- What service was denied
- The date the service was denied
- The date the appeal was denied
- Your name, address and phone number
You may talk with a lawyer or have another person represent you at the hearing. If you need help finding a lawyer, either:
- Visit The Northwest Justice Project
- Call the NW Justice CLEAR line at 1-888-201-1014
The judge will mail you his or her decision. If you disagree with the judge’s decision, you have the right to appeal either with:
- The Health Care Authority’s Board of Appeals
- An Independent Review
You must appeal the hearing decision within 21 calendar days of the date of mailing or the decision will be final.
An independent review is when a group of doctors who don’t work with us reviews your appeal. The doctors work for an Independent Review Organization (IRO). You aren’t required to have an independent review before an administrative hearing. To request an independent review, you must call and ask us.
If you don’t agree with the IRO’s decision, you can ask to have a judge from the Health Care Authority’s Board of Appeals review your case.
You have 21 calendar days to ask for a review judge after getting your IRO decision letter. The judge’s decision is final. You can request a review judge by phone or mail:
- To ask for a review judge by phone, call 1-844-728-5212
- To ask for a review judge by mail, write to:
HCA Board of Appeals
P.O. Box 42700
Olympia, WA 98504-2700