HEALTH CHOICE ®
Your Guide to Prestige Health Choice
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Welcome to Prestige Health Choice. We are happy to have you as a member. Prestige Health Choice members deserve a health care plan that is easy to use and understand.
About Prestige Health Choice
Dedicated to quality health care in your community
Committed to offer programs that increase awareness of health and wellness
Special programs for members with chronic conditions such as asthma, diabetes or heart disease
We want to help you and your family members be healthy. In your packet you will find the Member Handbook, which tells you about benefits and services, including:
Member Rights and Responsibilities
Special Health Programs
Appeals and Grievance Process
Important Numbers
Loss of Eligibility Process
Your Primary Care Physician (PCP)
Covered Services
Expanded Benefits
How to Change PCPs or Health Plans
Also included is:
Provider Directory with our doctors, hospitals, pharmacies, and other providers
Universal Patient Authorization Form
Initial Health Screening Questionnaire
Member Contact Form
It is very important that you fill out the Universal Patient Authorization Form and Initial Health Screening Questionnaire. Return only these forms in the stamped envelope with our return address right away. There is no need to fill out the Member Contact Form form unless your information has changed. Keep all other forms with you. Someone from our Member Services staff will be calling you in the next 90 days. This call is important. It helps us find out about your health and each family member enrolled with Prestige. It is especially important for your children so we make certain you are able to take them to see their doctor for their yearly check up. Please call our Member Services Department free of charge if you need help in:
Understanding any of our services or benefits
Hearing or vision impaired services
Changing PCPs or going to another plan
Call 1-855-355-9800 (TTY/TDD 1-855-358-5856) to talk to a Member Services Representative for any questions. For a list of Prestige providers, go to our website at www.prestigehealthcoice.com. Thank you, Prestige Member Services PRES-1422-02 ML1011_1401
HEALTH CHOICE ®
Thank you for choosing Prestige Health Choice. RE: Enrollment update Dear Member: We are pleased that you have chosen Prestige Health Choice as your health plan. If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Prestige or the state enrolls you in a plan, you will have 120 days* from the date of your first enrollment to try the Managed Care plan. During the first 120 days you can change Managed Care plans for any reason. After the 120 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next 8 months. Please refer to the Member Handbook for information about benefits and services. For a list of Prestige providers, go to our website at www.prestigehealthchoice.com. We’re here to help you. If you have questions, call Member Services at any time. The toll-free number is 1-855-355-9800. Thank you for choosing Prestige Health Choice.
Sincerely, Prestige Member Services
*This is an update from the “Enrollment” content stated on page 3 of the Member Handbook.
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This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/TDD 1-855-358-5856, las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7.
Table of Contents Prestige is For You!.......................................................................... 2 Your ID Card..................................................................................... 5 Your Primary Care Physician (PCP).............................................. 6 Continuity of Care............................................................................ 7 Helpful Questions to Get Care from Your Doctor..................... 9 When Someone is Sick or Hurt................................................... 10 Nurse Call Line............................................................................... 12 Your Prestige Benefits................................................................... 13 How your Pharmacy Benefits Work............................................ 16 How to Get Behavioral Health Services...................................... 17 Prior Authorization for Medical Services................................... 15 Case Management.......................................................................... 22 Rapid Response Gives Members Extra Help.............................. 22 Your Family and Prestige.............................................................. 23 Women’s Services............................................................................ 25 Your Rights and Responsibilities.................................................. 28 Protecting Your Privacy................................................................ 30 Fraud and Abuse............................................................................ 30 Grievances, Appeals and Medicaid Fair Hearings.................... 33 Important Telephone Numbers.................................................. 36
HEALTH CHOICE ®
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/TDD 1-855-358-5856, las 24 horas d el día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7. Prestige Health Choice | 1
Prestige is For You! Thank you for choosing Prestige. Prestige works with you and your family to keep you healthy. This member handbook tells you about the benefits of Prestige and how the plan can help you. The more you know about Prestige, the better we can serve you and your family. The decision whether or not to join Prestige will not affect your eligibility for Medicaid benefits. The Prestige provider directory is available in paper, and you can access the most updated provider listing online at www.prestigehealthchoice.com. The directory includes a list of participating providers along with their address, phone number and specialty. It also shows whether they are seeing new patients. To find out more information about a PCP or specialist or to request a directory, call Member Services tollfree at 1-855-355-9800. We look forward to serving you and your family and keeping you healthy. If you have any questions about the health plan, please call a Member Services representative at one of the numbers shown below.
In Other Languages and Formats We’ll provide this information to you in other languages and formats at no charge. We’ll also interpret this information over the phone in any language. Call Member Services at 1-855-355-9800. For TTY, call at 1-855-358-5856. Nosotros le podemos ofrecer esta información a usted en otros idiomas y formatos sin costo. También interpretaremos esta información por teléfono en cualquier idioma. Llame a Servicios al Miembro al 1-855-355-9800. Para los usuarios TTY, llame al 1-855-358-5856. If you are deaf or have trouble hearing, our TTY number is 1-855-358-5856. Charges for local and long distance relay calls will be the same as your regular local and long distance calling plan.
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Member Services toll-free: 1-855-355-9800 TTY for hearing impaired toll-free: 1-855-358-5856 24-hours, 7 days a week Toll-free Nurse Call Line: 1-855-398-5615 24-hours, 7 days a week health information from a registered nurse!
Enrolling When you are eligible for Medicaid, you need to choose a health plan. The Florida Department of Children and Families (DCF) determines who is eligible for Medicaid. Medicaid Choice Counseling can help people enroll with a Medicaid plan. They have enrollment specialists who can: Help you and your family enroll in a health plan. Answer questions about your choice of health plans. Help you if you decide to change health plans. You can talk to an enrollment specialist at Medicaid Choice Counseling by calling toll-free at 1-877-711-3662 (TTY users please call toll-free at 1-866-467-4970). You can also enroll by going to www.flmedicaidmanagedcare.com. Once you enroll in Prestige, we send you this welcome kit.
Enrollment If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Prestige or the state enrolls you in a plan, you will have 90 days from the date of your first enrollment to try the Managed Care Plan. During the first 90 days you can change Managed Care Plans for any reason. After the 90 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine months. This is called “lock-in.”
Open Enrollment If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called “open enrollment.” You do not have to change Managed Care Plans. If you choose to change plans during open enrollment, you will begin in the new plan at the end of your current enrollment year. Whether you pick a new plan or stay in the same plan, you will be locked into that plan for the next 12 months. Every year you may change Managed Care Plans during your 60 day open enrollment period.
How do I enroll my newborn? Prestige will cover your baby the day he or she is born. We will need your help to make sure we enroll your baby right away. Here are some things you can do to help us get your baby Medicaid.
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1. Call the Florida Department of Children and Families (DCF) toll-free at 1-866-762-2237 while you are pregnant. This will make sure your baby has Medicaid from the day he or she is born. DCF will help you to do this. They will give you a Medicaid number for your baby. 2. Call Prestige. Tell us the Medicaid number for your baby. You will need to pick a Prestige doctor for the baby before he or she is born. We can help you with this. If you do not pick a doctor by the time your baby is born, we will pick one for you. If you would like to change your baby’s doctor, please call us. 3. When the baby is born, call the Department of Children and Families (DCF) and us. The State will turn on your baby’s Medicaid ID number once the hospital or doctor tells the state of the birth.
Reinstatement to the Plan If you lose your eligibility and then are reassigned to Prestige, we will send you a letter. That letter will tell you the new date that you are a Prestige member. We will also tell you who your PCP will be and ask you to call us if you need a new member card or member handbook. This letter will also tell you if you are eligible for open enrollment and how to change plans for cause. Call Member Services if any information about you or your family changes. Call Member Services if your mailing address changes. You must also contact the Social Security Administration (SSA) at 1-800-772-1213 (TTY 1-800-325-0778), or the Department of Children and Families (DCF) at 1-866-762-2237 with these changes.
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Your ID Card
Always Carry it With You Every member of Prestige gets a Member ID card. When you get your Member ID card, be sure to check to make sure everything on it is correct. If you have not received your card or if it has been lost, please call Member Services toll-free at 1-855-355-9800. We will mail you a new card. Your Prestige Member ID card is very important. You should carry it with you at all times. You must show your Prestige Member ID card whenever you get services from doctors, hospitals, pharmacies and other Prestige providers. Do not let anyone else use your Prestige Member ID card. If you do, you may have to pay for the service, or you could lose your benefits. What’s on Your ID Card? Name Prestige ID number Date of birth Medicaid ID # Primary Care Physician’s (PCP’s) name PCP’s phone number Important information for pharmacies
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Your Primary Care Provider (PCP)
A Personal Doctor for You When you join Prestige, you must choose a doctor from the Prestige provider directory to help you get health care. This doctor is your Primary Care Physician (PCP). You can choose a different PCP for each family member in Prestige or you can choose one PCP for the entire family. If you do not choose a PCP, we will choose one for you. If you do not have a provider directory, please call Member Services or visit our website at www.prestigehealthchoice.com. Providers in the Prestige directory have agreed to take care of Prestige members. These providers have met Prestige’s standards for quality of care. To find out more about providers listed in the directory, call Member Services or go online at www.prestigehealthchoice.com. Your PCP cares about you and your health and arranges all your health care. When you need medical care, call your PCP’s office first – at any time, day or night. Your PCP will know how to help you. If you need to go to a specialist doctor or to the hospital, your PCP can make all the plans for you. Some PCPs have trained health care assistants who work with them. They may help your PCP take care of you. There may be times when you will see one of these health care assistants. If you have questions, call Member Services toll-free at 1-855-355-9800. The types of assistants that may help your PCP are: Physician Assistants
Medical Residents
Nurse Practitioners
Nurse Midwives
Family practice, general practice, pediatric, some internal medicine, some Obstetrical/ Gynecological (OB/GYN) doctors and some nurse practitioners can serve as your PCP. A specialist doctor generally cannot serve as your PCP. Your PCP will: Listen to your health problems and answer all questions. Keep a record of your health history. Provide timely medical care to you. Give physical exams and immunizations (shots) when needed. Write prescriptions when needed. Educate you about good health habits and disease prevention.
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Refer you to a specialist doctor when needed. Arrange for hospital care when needed. Explain your health problems and treatment you need to take care of them. Return phone calls as soon as possible. Treat you and your family with kindness and respect.
Dual-Eligible (Medicare and Medicaid) If you have Medicare and are eligible for Medicaid benefits, that means you are dual eligible. Dual-eligible enrollees receive Primary Care Physician (PCP) services through Medicare, and have a Medicare PCP. Dual-eligible members do not have to choose a new PCP through Prestige.
Hints to Help You with Your PCP Visits Your PCP is available to you 24 hours a day. However, it may be best to call during normal business hours if you want to talk to someone from the office. Here are the standards that Prestige and your PCP have agreed upon for making appointments: Emergencies will be seen right away.
Routine sick care will be scheduled within one week.
Urgent care will be seen within one day.
Well-care visits will be scheduled within one month.
If Your PCP Leaves Prestige: When we know that your PCP is leaving the Prestige network, we will let you know by mail and give you a new PCP in your area. You may choose a different PCP by calling Member Services toll-free at 1-855-355-9800. For an updated PCP directory, call Member Services or visit the Prestige website at www.prestigehealthchoice.com.
Continuity of Care In certain situations, you can continue ongoing treatment at no cost with a health care provider who is not in the Prestige network. This can happen when: You are a Prestige member who is getting ongoing treatment from a health care provider who is not in the Prestige network or has left the Prestige network. When this happens, Prestige will: Allow new members to receive ongoing care from a health care provider who is not in the Prestige network for up to 60 days from the date the member is enrolled in Prestige. Allow new members who are pregnant to get ongoing treatment from their current health care provider even if the doctor is not in the Prestige network. You will be able to see this doctor until you deliver your baby. Allow members to get ongoing treatment from a health care provider who has left the Prestige network for up to six months from the date Prestige tells the member that the health care provider will no longer be in the Prestige network. For more information on continuity of care call Member Services toll-free at 1-855-355-9800.
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More About Your PCP
Get to Know Your PCP – Now! Make an appointment with your PCP right away, before you get sick and need medical care. Call your PCP office and make an appointment for a medical checkup. Make your appointment as soon as you can.
Arrange for Transportation If getting to your appointment is a problem please call toll free at 1-855-371-3968. They will assist you in the coordination of transportation for all medically necessary trips. You may also call Prestige Member Services tollfree at 1-855-355-9800 for help getting transportation.
Keep Your Appointments Your doctor’s office saves your appointment time just for you. If you have to cancel your appointment, give your doctor’s office at least a 24-hour notice.
At the Office When you get to the PCP’s office, you will need to give information about you or your family’s health and medical history. Answer all of the questions as best you can. If there is something you do not understand, ask for help. This information is very important for your PCP to keep you and your family healthy. The PCP will then give you or your family member a medical checkup. He or she will also need to talk to you about your health or your family member’s health. Ask as many questions as you like. You may always stay in the exam room with your child. Listen carefully to any directions the PCP gives you. If you do not understand what your PCP wants you to do, call the PCP’s office — day or night.
Changing PCPs You may change your PCP by calling Member Services. We will send you a provider directory or help you choose a PCP over the phone. You can also find the provider directory on our website at www.prestigehealthchoice.com. You will get a new ID card when you change your PCP. When you get the new card, please destroy your old card. Call Member Services toll-free at 1-855-355-9800 for more information about changing your PCP.
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Helpful Questions
Helpful Questions to Get Care from Your Doctor This list will help you with your medical concerns and questions. Answer the first set of questions before you visit your PCP. Your PCP will help you answer questions 2 to 4. Call Member Services toll free at 1-855-355-9800 to get more copies of The Helpful Questions Form. 1. Tell the doctor what is wrong: a. If you have a problem, when did it start? b. What are the symptoms (signs)? c. Have you ever had this problem before? d. If so, when? What did you do about it? 2. Ask your doctor the following: a. What is the problem called? b. What will happen as a result of the problem? c. How do I treat myself at home? 3. If your doctor gives you medicine or treatment, ask your doctor the following: a. What is the name of the medicine or treatment? b. Why do I need to take it? c. What are the risks and side effects? d. What are the other choices? e. How do I take the medicine? f. How do I get ready for the treatment? 4. Before you leave the doctor’s office, find out the following: a. Should I return for a follow up appointment? b. Should I call for test results? If so, when? c. Are there any danger signs I need to look for? d. Is there anything else I need to know? Prestige Health Choice | 9
When Someone is Sick or Hurt Always call your PCP as soon as you can. If the problem is not an emergency, the PCP can arrange for you to come into the office for care.
Emergency and Urgent Care An emergency is a health problem that may be serious and a danger to your life and ability to get around. The problem may be with any body part or organ. If you are pregnant, this includes you and your unborn baby. You should go to the hospital emergency room if there is a life-threatening illness or injury. If you are not sure that you have an emergency, call your PCP or the Nurse Call Line toll-free at 1-855-398-5615. If you have an emergency, call 911 or go to the nearest emergency room. Show your Prestige ID card. Call your PCP and Prestige as soon as you can. You do not need a prior authorization to go to the emergency room. Urgent care is a medical condition that requires care within 48 hours. If you don’t get treatment for the condition in two days or less, it could become an emergency.
Care After an Emergency Once you leave the hospital, you need to get care. We call this “post-stabilization” service. This will keep you healthy. These services do not need prior authorization (pre-approval).
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Nights and Weekends Your PCP can help you 24 hours a day, 7 days a week. If you get sick after the PCP’s office is closed, call the office anyway. Someone will answer, and the PCP will call you back. Call as early in the day as possible. Try not to wait until late at night. If you have the problem during the day, you should call during the day. If you cannot reach the PCP, call the Nurse Call Line toll-free 1-855-398-5615.
Out of Town If you or a family member get sick and need medical care when out of the Prestige service area, call Member Services toll-free at 1-855-355-9800. We will help you find a doctor wherever you are.
Here is a guide to help you decide if you should go to the emergency room: Call your doctor for: Sore throat Flu or cold Back pain Frequent urination Fever of 99º to 102º (adults & children ages 3 months or older) Earaches Toothache(s)
Call 911 or go to the hospital emergency room if you or your family member has: A serious accident Eye damage Severe bleeding A fever of 100.5º or higher for infants 0 to 2 months old Severe cuts or burns Broken bone Blood in vomit A knife or gunshot wound Chest pain Difficulty breathing Unconsciousness Poisoning Nearly drowned No pulse or heartbeat A stroke
Specialists A specialist is a doctor who practices a certain area of medicine. Your PCP is trained to treat most medical problems. However, there may be times when you need to see a doctor who is a specialist. The PCP will help you decide when to see a specialist and will help you see a Prestige specialist. Prestige covers your visits to contracted specialists in our network without prior authorization. There is no limit to how many times you may see the specialists.
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Specialist doctors can include: Heart doctors (cardiologists)
Doctors for bones and joints (orthopedists)
Skin doctors (dermatologists)
Foot doctors (podiatrists)
Doctors for women and girls (gynecologists/GYN)
Eye doctors (ophthalmologists)
Doctors for women who are pregnant (obstetricians/OB/Birthing Centers)
Doctors that perform surgeries (surgeons)
Always check with your PCP before going to a specialist. Women and girls can go to an OB/GYN at any time. For a list of Prestige specialist doctors, call Member Services toll-free at 1-855-355-9800 or visit our website at www.prestigehealthchoice.com. If you want more information about a Prestige provider, call Member Services toll-free at 1-855-355-9800. You can find out things like where they went to medical school or if they are board certified.
Out-of-Network Specialists If you need to see a specialist who is not in the Prestige network, you will need to have prior authorization (pre-approval) from Prestige. Ask your PCP to help you. You may have to pay for services if you see a provider that is not part of the Prestige Network.
Second Opinion If you want to know what another doctor says about your health problem, you may get a second opinion at no cost to you. Call Prestige Member Services toll-free at 1-855-355-9800 or ask your PCP for the name of another doctor who is a Prestige doctor. Make sure you have a referral form from your PCP or Prestige before calling the second doctor. Call the second doctor to make an appointment. You can get help by calling Member Services toll-free at 1-855-355-9800.
Nurse Call Line Prestige members have access to a 24-hour Nurse Call Line. The Nurse Call Line is a free service you can call any time. A nurse will listen to your health care problems or questions and help you make good health care decisions. The next time you are sick, hurt, or need health information, call the Nurse Call Line toll-free at 1-855-398-5615.
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Your Prestige Benefits
Services covered by Prestige and what to do: There are no co-payments for the services listed below. But remember, you may be responsible to pay for services if you find out ahead of time that Prestige does not cover the services. You may also have to pay for the services if you go to a provider that is not in the Prestige network. It is important to check with your PCP or call Member Services toll-free at 1-855-355-9800 if you have questions. Services
What to do
Adult Well Visits are regular medical checkups that help keep you healthy.
Make an appointment with your PCP.
Behavioral Health Services are inpatient and outpatient hospital services and psychiatric doctor services. Mental health and case management services are available. You can get these services in the community and in your home. See the section on the How to Get Behavioral Health Services for more information (pg. 16).
Make an appointment with a Prestige behavioral health provider.
Child Health Check-Ups (CHCUPs) are regular medical checkups from birth to under age 21; visits may include immunizations (shots). See the Child Health Check-up Program section for more information.
Make an appointment with your child’s doctor for these services.
Chiropractic services are limited to one visit per day and up to 24 visits a year. Referral needed for members under the age of 21.
Make an appointment with a Prestige chiropractor. Authorization is required for any visit in excess of the 24 visits a year, for members under the age of 21.
Durable Medical Equipment (DME) includes medically necessary equipment and supplies when ordered by a physician. There are some limits for members 21 years of age and older. Prestige must pre-approve DME items.
Call your PCP if you need DME services. Call Member Services toll-free at 1-855-355-9800, because sometimes DME requires pre-approval.
Dental Care for Adults are services for members ages 21 and older. They can receive two exams, two cleanings, four simple extractions, two surgical extractions, three amalgam fillings per year and one x-ray every two years.
Make an appointment with a participating dentist.
Dental Care for Children are services for members 20 years of age and younger.
Make an appointment with a participating dentist.
Emergency Transportation
Call 911 if there is an emergency.
Eye Care for Children are services for members 20 years of age or younger. The benefit includes up to two eye exams and two pairs of eyeglasses every 365 days. You may be able to get contact lenses. Talk to your doctor.
Make an appointment with a participating doctor.
Eye Care for Adults are services for members 21 years of age and older and include up to one eye exam and one pair of eyeglasses every 365 days. You may be able to get contact lenses, talk to your doctor.
Make an appointment with a participating doctor.
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Services
What to do
Family Planning services let you plan the size of your family or think about when you want to have children. They include information, diagnostic procedures, medical tests, birth control drugs and supplies, sterilization and follow up. You do not need prior approval to get family planning services.
Make an appointment with a participating doctor.
Hearing covers hearing tests and one hearing aid every other year.
Make an appointment with a participating doctor.
Home Health Care services can include skilled nursing, home health aide, physical, occupational and speech therapy services in your home. You will need a doctor’s order (such as a prescription) for these services.
Call Member Services toll-free at 1-855-355-9800 if you need these services.
Inpatient Care are services provided under the direction of a doctor when you are admitted to a hospital for a stay that is more than 24 hours. It includes room and board, medical supplies and equipment, medications and other hospital services.
Speak to your doctor. Prior authorization is required for all non-emergency admissions.
Lab and X-ray services are those that a doctor orders. In-network providers and laboratory facilities provide these services.
Call your PCP.
Life-Threatening Emergencies are when you need medical care right away because of a danger to your life or eyesight if not treated right away.
Call 911 or go to the nearest emergency room.
Maternity Services include nursing review and counseling, nutrition review, prenatal (pre-birth), delivery (having the baby), postpartum (after birth) services and nursery services (your baby’s care while in the hospital). See the section Special Care For Pregnant Members for more information.
Call Member Services toll-free at 1-855-355-9800 for a list of providers.
Outpatient Services are preventive diagnostic, therapeutic, rehabilitative, surgical and emergency services received for the treatment of a disease or injury at an outpatient/ ambulatory care facility for a period of time under 24 hours.
Call your PCP.
Pharmacy (prescriptions and over-the-counter) Prestige can give you a drug list that will tell you what medicines we cover. Over-the-counter medicine is limited to $25 per month, per household (max $50 per year). You can also get this information on our website at www.prestigehealthchoice.com. Click on “Members” and “Find a MedicineSearchable.” Primary Care Physician (PCP) Visits include visits to the personal doctor you chose from the Prestige provider directory.
Make an appointment with your PCP.
Specialist Visits are visits to a doctor who practices a certain area of medicine.
Talk to your PCP.
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Services
What to do
Therapy Services include physical, occupational, speech and respiratory therapy for all members under the age of 21. Prestige covers these therapies for members over 21, but there are some limits.
Talk to your doctor if you need these services.
Transportation Services are available.
Please contact our transportation vendor at 1-855-381-3778. For questions, please contact Member Services at 1-855-355-9800.
Well-woman visits include regular medical checkups for women including annual mammograms and Pap tests.
Talk to your PCP for more information.
For counseling or referral services not covered due to moral or religious objections.
Contact Member Services for State service options.
Prior Authorization for Medical Services Prestige must approve some services before your doctor can help you get them. We call this “prior authorization.” Please talk to your doctor about the services you need and if they will need prior authorization.
Prior Authorization Process Your doctor gives the information to Prestige for review. If a Prestige nurse cannot approve the request, a Prestige doctor will review the request. If Prestige approves the request, we will contact your doctor. If Prestige does not approve the request, we will send a letter to you and your doctor. We will tell you why we did not approve the request. If you do not agree with the decision, you may file a grievance or an appeal. See page 33 for more information on grievances and appeals. If you need help, call Member Services toll-free at 1-855-355-9800.
Hospital Admissions When you are admitted to the hospital, prior approval is needed. In most cases, your doctor will handle this for you. You should talk with your doctor if you have a question about hospital admissions. You can also call Member Services toll-free at 1-855-355-9800 to ask questions.
Concurrent Review A concurrent review is a review of your care while you are using certain services. Examples of these services are hospital stays, therapy services and home health care. Prestige will begin this review when needed. Prestige Health Choice | 15
How Your Pharmacy Benefits Work Prescriptions/Medicines
Over-the-Counter Medicine
Your doctor will write you a prescription. You must pick the medicine up at a pharmacy that is part of the Prestige network. You’ll find a list of pharmacies in your Prestige printed provider directory. The provider directory is available online at www.prestigehealthchoice.com.
Prestige covers some over-the-counter medicine. There is a limit to how much over-the-counter medicine you can get. Prestige allows each household up to $25 per month (max $50 per year). Visit www.prestigehealthchoice.com for a list of approved products.
There is no cost to you for prescriptions. Show your Prestige member card when you get your prescriptions. If you have any questions, call Pharmacy Member Services toll-free at 1-855-371-3963 if you need help.
Participating Pharmacies
Prior Authorization (Pre-Approval) Your doctor may write a prescription for a medicine that is not on the Prestige drug listing. Your doctor will need to send us a prior authorization request form. We will review and let your doctor know our decision. If Prestige does not approve the medicine, you will get a letter that will tell you why. The letter will tell you how to make an appeal if you want to do so.
You can use any of our participating pharmacies. If you need a list of pharmacies, call Member Services toll-free at 1-855-355-9800 (TTY/TDD 1-855-358-5856). You can also go to our website at www.prestigehealthchoice.com. Go to “Member” and then go to “Find a Pharmacy.”
Pharmacy Member Services If you have questions, please call the Pharmacy Member Services toll-free at 1-855-371-3963.
Informed Consent A parent or guardian must sign informed consent for psychotropic medicines for children under 13 years old. Your PCP will ask you to sign a form. Please ask your PCP for help.
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How to Get Behavioral Health Services If you are having any of the following feelings or problems, you should contact a behavioral health provider: Always feeling sad
Having difficulty sleeping
Difficulty concentrating
Feeling hopeless
Having a poor appetite
Irritability
Feeling helpless
Weight loss
Feeling worthless
Loss of interest
Constant pain like headaches, stomach aches and back aches
You can get help finding a behavioral health provider by: Calling toll-free 1-855-355-9800 (TTY: 1-855-358-5856)
Going to our website at www.prestigehealthchoice.com
Looking at our provider directory Someone is there to help you 24 hours a day, 7 days a week. You will be able to call them for an appointment. Please call so we can help you find the services you need. The Prestige access to care standards for behavioral health services and referrals are as follows: Urgent care will be seen within one day. Routine patient care will be scheduled within one week.
Well-care visits will be scheduled within one month.
You can also ask for a different behavioral health care coordinator/case manager or direct service behavioral health care provider in our network if one is available. Remember: You do not need a referral from your PCP. You’ll get an approval for services when you call.
You may have to pay the bill if you see a provider without getting an approval first, or if you go to a provider that is not part of our network.
Some of the services you may need for you or your family: Individual, family or group therapy
Evaluations Treatment planning
Individual and family assessments
Case management
Day treatment for adults and children
Therapeutic behavioral on-site services for children and teenagers
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Emergencies and Getting Care Away from Home: If you think you are a danger to yourself or others, CALL 911 or go to the nearest emergency room. Once you are in a safe place, call your PCP if you can. Follow up with your doctor within 24 to 48 hours. When you have gotten emergency care out of the area, Prestige will make plans to transfer you to an in-network hospital or provider once you are stable.
Care After an Emergency Once you leave the hospital after a mental health emergency, you need to get care. We call this “post-stabilization” service. This may help keep you from having another mental health emergency. Post-stabilization services are given 24 hours a day, 7 days a week. These services do not need prior authorization (pre-approval).
Behavioral Health and Substance Abuse Treatment Prestige members can receive behavioral health and/or substance abuse treatment. Please call Member Services toll-free at 1-855-355-9800 with questions. You can also talk to your Primary Care Physician (PCP) who can direct you these services.
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Healthy Behavior Programs Small decisions like what we eat and how we deal with stress have a big effect on our health. With this in mind, Prestige Health Choice has three healthy behavior programs. You can earn rewards for reaching different health goals! When Prestige gets your signed commitment form we’ll mail your first $10 gift card. There are limits on how many gift cards you can earn. Please remember that rewards are non-transferable. If you leave Prestige Health Choice for more than 180 days, you may not receive your reward. If you have questions or want to join any of these programs please call Member Services at 1-855-355-9800. Weight Loss Being overweight can raise the risk for many diseases, including Heart Disease, Type 2 Diabetes, and some types of cancer. You may join the weight loss program if your doctor says that you have a Body Mass Index (BMI) of 35 or more. You will receive a $10 gift card for visiting your doctor and sending Prestige your commitment form! You can earn more gift cards by making an appointment to see a Dietician or Nutritionist, or for following up with your doctor. If you are in the weight loss program for three months and lower your BMI, you can earn a $20 gift card! Quitting Tobacco We know that quitting smoking is not easy, but it is worth it. With the help of certified coaches, an online program, and face to face classes, you will have the support you need to quit. When you sign up you will get a $10 gift card and free over the counter nicotine patches, lozenges, and gum. You can earn another $10 gift cards for attending group sessions and seminars on quitting. When you finish the program and mail your “Certificate of Completion” to a Prestige Care Manager, you will earn a $30 gift card! Alcohol and Substance Abuse Recovery You have a better chance of living without drugs and alcohol when you join a medically supported program that is overseen by your doctor. That’s why Prestige offers an Alcohol and Substance Abuse Recovery Program. We can help you overcome alcohol and/or substance abuse with guidance from Care Managers, your doctor, and joining local community groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Committing to quit is a big step, and Prestige will mail you a $10 gift card for signing up! After you sign up a Care Manager will help you join a local support group. Prestige will mail you a $10 gift card for being 30 days sober, and another $10 gift card for 90 days of sobriety. Prestige wants to help you stay sober, and will send a $20 gift card to help you celebrate 180 days of sobriety.
Physician Incentive Payments Primary Care Physicians (PCPs) may receive extra payment for some services like immunizations (shots). When PCPs meet other quality, service and performance standards, they may get additional payments. Call Member Services for more information.
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Services Prestige Excludes/Does Not Cover Prestige excludes, or doesn’t cover, some services. Always contact Prestige if you have questions about your benefits. These are the types of services not covered: Services not medically-necessary
Infertility services
Services provided by an out of network physician. We make exceptions for emergency services, family planning services or when the requested service is not available through Prestige. You can see an out of network provider during your Continuity of Care time when you first join Prestige. See page 7 for more information on Continuity of Care.
Elective abortions Elective cosmetic surgery Experimental/investigational drugs, procedures or equipment Services provided outside of the United States
Prestige may not cover all of your health care expenses. You may have to pay for services if you find out ahead of time that Prestige does not cover the services, or if you go to an out of network provider. It is important to check with your doctor or call Member Services toll-free at 1-855-355-9800 if you have any questions. There may be some services that Prestige does not cover, but might be covered under Medicaid. Please see the local field Medicaid office for the county you live in below. They will tell you if you will be billed for these services. The local field Medicaid office can also direct you to organizations in your local community that offer health programs.
Aging and Disability Resource Centers (ADRCs) Area Agency on Aging Offices:
Florida Medicaid AHCA Field Offices: Field 2: Bay, Calhoun, Franklin Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington counties.
1-800-226-7690
PSA 2: Bay, Calhoun, Franklin Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington counties.
1-850-488-0055
Field 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union counties.
1-800-803-3245
PSA 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union counties.
1-352-378-6649
Field 5: Pasco and Pinellas counties.
1-800-299-4844
PSA 5: Pasco and Pinellas counties.
1-727-570-9696
Field 6: Hardee, Highlands, Hillsborough, Manatee, and Polk counties.
1-800-226-2316
PSA 6: Hardee, Highlands, Hillsborough, Manatee, and Polk counties.
1-813-740-3888
Field 7: Brevard, Orange, Osceola, and Seminole Counties.
1-877-254-1055
PSA 7: Brevard, Orange, Osceola, and Seminole Counties.
1-407-514-1800
Field 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota counties.
1-800-226-6735
PSA 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota counties.
1-239-652-9600
Field 9: Martin, Okeechobee, Palm Beach, Indian River, and St. Lucie counties.
1-800-226-5082
PSA 9: Martin, Okeechobee, Palm Beach, Indian River, and St. Lucie counties.
1-561-684-5885
Field 11: Miami-Dade and Monroe counties.
1-800-953-0555
PSA 11: Miami-Dade and Monroe counties.
1-305-607-6500
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We Pay Attention to Your Care Prestige’s doctors and nurses check the services given to all members. They also make decisions about medicallynecessary care and services.
Medical Necessity Prestige will pay for care you need that is medically-necessary. This means that a medical service is needed to find out what is wrong with you, relieve pain or prevent you from getting sick. A provider must give treatment to you in a way that follows a good practice of medicine. A provider must also give the care to you in a place that is safe and effective. If you need help understanding this information, please call Member Services toll-free at 1-855-355-9800. Prestige does not: Reward health care providers for denying, limiting or delaying benefits or health care services. Give incentives to staff or providers for making decisions about medically necessary services. Give rewards to provide less health care coverage and services.
Dedication to Quality Care Prestige has a mission to help people get care, stay well and build healthy communities. We have a Quality Improvement (QI) program. This program looks for ways to improve your health and your family’s health. We look for ways we can serve you better. The QI program: Looks for areas that need to be improved in medical and preventive services. Offers disease and health programs for you. Provides outreach to members and gives health education. Performs medical and service area studies when they are needed. Watches the quality of care and services given by Prestige providers, like medical, dental, vision and pharmacy. Creates programs for members with special health care needs. Works with providers to improve our services. Surveys members and providers and uses the answers to improve our services. Monitors itself to make sure it is working to improve services. If you would like more information about our quality improvement goals, activities or outcomes, please call Member Services toll-free at 1-855-355-9800.
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PCPs, hospital and doctor groups receive payment for the services they give you. PCPs may get extra pay for some services, like shots. When PCPs meet other quality, service or performance standards set by Prestige, they may get extra payments. You can also get information about how Prestige rates on certain performance measures for some types of services. If you believe you or your family did not get quality care, please call Member Services. Prestige will look into your concern. For a copy of Prestige’s preventive health and clinical practice guidelines, call Member Services toll-free at 1-855-355-9800. You can also find them at www.prestigehealthchoice.com.
Case Management Prestige has a case management program to help you better understand and manage health problems. This is a service for members with special needs or who need help. Examples of special needs are long-term illnesses, injuries and pregnancies. Programs include management of asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, and Sickle Cell disease. You do not need a referral from your PCP for these programs. Our goal is to help you know how to use your benefits and get the care you need. Our team will work with your PCP and assist with your health care needs. They will arrange home health visits and provide medical support items needed to help manage your health condition. They will also send you information about your condition. Licensed nurses or social workers called care managers support you over the phone. They also help to arrange other services to help you quit smoking or other community support activities. Care managers help you better understand your condition and will work with you to develop a plan to help you address your special needs. They will help arrange health care and follow up by working with your PCP to ensure you get the care you need. Please call Member Services toll-free at 1-855-355-9800 if you have any questions or want more information about these programs.
Rapid Response Gives Members Extra Help The Rapid Response and Outreach Team helps members with health-related issues. All Prestige members can call toll-free at 1-855-371-8072 for help with their health care. We are available to help with urgent issues. We also provide support in figuring out health care services. Sometimes we all need a little help with our medical needs. The Rapid Response and Outreach Team will answer your questions and help solve problems. As an example we help schedule doctors appointments. We can find transportation options. We can also remind you when important health tests are due. The Rapid Response and Outreach Team has a network of community resources, which provide housing support, utility assistance and a variety of other services. We help you with these issues so you can focus on caring for your loved ones and your health.
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Do you have a question about your health plan? Do you need to know how to take a medicine? Do you need a broken wheel-chair or other health equipment fixed? The Rapid Response and Outreach Team can help you get answers to your questions. We can help find the right services to support you and your family. You can reach the Rapid Response and Outreach Team at 1-855-371-8072. The Rapid Response line is toll-free and open from 8:00 a.m. until 6:30 p.m. EST, Monday – Friday. You can always call Member Services toll-free 24 hours a day, 7 days a week at 1-855-355-9800.
Your Family and Prestige Child Health Check-Up Program (CHCUP) Prestige has a Child Health Check-Up Program (CHCUP) for members younger than 21 years old. The CHCUP program helps you get the health care your child needs. This can help prevent or find problems as early as possible so your child can stay healthy. Please call Prestige toll-free at 1-855-355-9800. We can help you get the health care your child needs and help you select a PCP for your child. You can take your child to a pediatrician, family practice doctor, or other Prestige network providers. The provider you choose can be your child’s Prestige PCP. The PCP will make sure your child gets needed check-ups and immunizations (shots), answer your medical questions, and help your child stay healthy. Once you become a Prestige member, please call your child’s PCP to make your first appointment. Prestige wants parents to make sure their children are getting regular medical checkups. You do not need a referral for these visits.
Why should my child have wellness or check-up visits? All Prestige members need to have regular wellness visits with their PCP to stay healthy. Babies need to see their PCP seven times by the time they are 12 months old and more times if they are sick. If your child has special health needs such as asthma or diabetes, we can help your child get checkups, tests, and shots.
How often should my child have a Child Health Check-up? The first well-child visit will happen in the hospital right after your baby is born. For the next visits, you must take your baby to his or her PCP’s office. You must set up a well-child visit with the doctor when the baby is: 1 month old 2, 3, 6, 9, 12, 15, 18 and 24 months Once per year from 2 to 20 years old Be sure to make these appointments. Please take your child to the PCP for all appointments.
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What areas of my child’s health will be checked? A review of your child’s physical and mental growth A complete physical exam Nutritional and developmental review Vision, hearing and dental tests (screenings) Lab tests (including blood lead testing for children ages 12 and 24 months) Immunizations (shots) – These are important to help the body fight disease. Children must have all of their shots before starting school. Health education and help with preventive care Diagnosis and treatment Referral and follow-up, as needed
Will my provider charge me for my child’s Child Health Check-Up Program (CHCUP) medical visit? No. CHCUP visits are part of your benefits as a Prestige member.
How can I make sure my child gets a CHCUP medical visit? Call your child’s PCP office to make an appointment. When you call for an appointment, tell the PCP’s office that your child is a Prestige member. If you need help or have problems, call Prestige Member Services toll-free at 1-855-355-9800. If you need transportation to the PCP’s office, call Member Services toll-free at 1-855-355-9800 to help you arrange transportation to medical appointments.
Blood Lead Testing Your child’s PCP should test your child for lead poisoning. Many items such as children’s toys, jewelry and clothes are being found to have high levels of lead. Your child needs a blood lead test at 12 months and 24 months. Your child should get the test between 36 and 72 months if your child has never been tested before. Your child’s doctor will take a blood sample by pricking the finger or taking blood from a vein. This test will tell if your child has harmful lead in his or her blood.
Vision Screening Your child’s PCP should check your child’s vision at every well-child visit.
Hearing Screening Your child’s PCP should check your child’s hearing at every well-child visit. 24 | Prestige Health Choice
Dental Screening Your child should have his or her teeth and gums checked by his or her PCP as a part of the regular well-child visits. At age three, your child should begin seeing a dentist every six months.
Immunizations (Shots) It is important for your child to get his or her shots on time. Take your child to the doctor when his or her PCP says a shot is needed.
Women’s Services Well-woman visits are important for good health for adult women. Annual mammograms and cervical cancer screenings (Pap tests) are important steps in maintaining a woman’s health. Contact your PCP for help to get wellwoman visits, tests, and family planning services.
Picking an OB/GYN Female members can see a Prestige obstetrician and/or gynecologist (OB/GYN) for OB/GYN health needs. These services include well-woman visits, prenatal care (visits while you are pregnant), care for any female medical condition, family planning and referral to a special doctor within the network. You do not need a referral from your PCP to see your OB/GYN. If you do not want to go to an OB/GYN, your PCP may be able to treat you for your OB/ GYN health needs. Ask your PCP if he or she can give you OB/GYN care. If not, you will need to see an OB/GYN. You will find a list of network OB/GYNs in the Prestige provider directory. While you are pregnant, your OB/GYN can become your PCP. If you need help picking an OB/GYN, call Member Services.
If You Think You Are Pregnant If you think you are pregnant, call your PCP or OB/GYN doctor right away. It is very important you see your PCP or OB/GYN when you are pregnant. We call this “prenatal care.” It helps you and your baby stay healthy. You do not need a referral to see your PCP or OB/GYN doctor. If you do not have an OB doctor, contact Member Services toll-free at 1-855-355-9800 for help picking an OB/GYN doctor. If you are pregnant, remember to call the Florida Department of Children and Families (DCF) toll-free at1-866-762-2237. You will need to update your information with them. You will need to call Member Services toll- free at 1-855-355-9800 when you find out you are pregnant. This will help your baby get Prestige benefits when he or she is born. You will need to choose a PCP for your baby in your last three months (trimester) of pregnancy. The third trimester begins in week 28 and lasts through the end of your pregnancy.
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Special Care for Pregnant Members Bright StartSM is the Prestige program for all pregnant members.
Bright Start Program – If You are Pregnant Early and complete health care before your child’s birth is the key to having a healthy baby! Bright StartSM by Prestige helps moms-to-be make healthy choices for themselves and their unborn baby.
Who can be a member of Bright Start? Any Prestige member who is pregnant can be a member of Bright Start.
Does Bright Start cost anything? Bright Start is FREE to Prestige members.
How does Prestige help Bright Start members? Your health care provider will decide if your pregnancy is “low risk” or “high risk.” If the pregnancy is low risk, you will talk to a Bright Start Outreach Coordinator about your needs, services, and classes you may attend. The Bright Start Outreach Coordinator will also help you choose a Prestige OB/ GYN and a PCP for your baby. They will also mail information to you during your pregnancy. After your baby is born, the Bright Start Outreach Coordinator will talk with you to help you get health services for your baby.
What if my pregnancy is “high-risk?” You might be at high-risk if: You are under 18 years old. You had a problem pregnancy in the past.
Your doctor tells you that your pregnancy is “highrisk.”
Each Bright Start high-risk member works with a special nurse. The nurse helps you get the care you need. The nurse will give you information about your needs. The nurse will work with you to get special services you may need including social work, special diet, referrals to specialist doctors, home health services or help from local agencies.
What about WIC (Women, Infants, and Children)? If you are pregnant, you need to take good care of your health. You may be able to get healthy food from the WIC program; please call Member Services toll-free at 1-855-355-9800. Prestige will help you with a referral to a WIC provider.
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When you are pregnant you will need to see your PCP or OB/GYN at least: Every four weeks for the first 32 weeks Every two weeks until week 36 Then weekly until delivery Your PCP or OB/GYN may want to see you more often based on your health needs.
Having a Baby When you deliver your baby, you and the baby may stay in the hospital at least: 48 hours after a vaginal delivery 96 hours after a cesarean section (C-section) You may stay in the hospital less time if your PCP or OB/GYN and the baby’s doctor see that you and your baby are doing well. If you and your baby leave the hospital early, your PCP or OB/GYN may ask you to have an office or in-home nurse visit within 48 hours. After you have your baby, remember to call Prestige Member Services as soon as you can to tell us you had your baby. We will need to get information about your baby, too. You may have already picked a PCP for your baby before he or she was born. If not, we can help you pick a PCP for him or her. You must also call your Florida Department of Children and Families (DCF) caseworker when you have your baby.
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Your Rights and Responsibilities
Your Responsibilities As a Prestige Member Keeping yourself and your family healthy can be easy. Here is the list of what you need to do. 1. Read your member handbook. Call Member Services if you have questions. 2. Choose your new Primary Care Physician (PCP) when you get your welcome kit. 3. Help your new PCP care for you and your family. Fill out all information sheets carefully. Help your PCP get your records from your previous doctor. 4. Help your doctors manage your care. Follow the care plan they make for you. If your care plan does not work, tell your PCP. They want you to feel better. They will adjust your care plan to make it work. 5. Keep your appointments for all regular care. Examples are Child Health Check-ups (CHCUPs), family planning, and health screenings. 6. Get a referral from your PCP before you see a specialist, non-participating provider or go to the hospital. Only go to the hospitals or specialists your PCP recommends. If you visit a non-participating provider you will need prior authorization by calling 1-855-371-8074. 7. If your Prestige ID card is ever lost or stolen, call Member Services. 8. Present your ID card any time you receive medical services from a doctor, hospital, clinic, or pharmacy. 9. Call your PCP when you feel sick. Do not wait. Go to the nearest emergency room if you feel your life is in danger. 10. Call Member Services if any information about you or your family changes. Call Member Services if your mailing or home address changes. This helps us avoid most problems. You must also contact the Department of Children and Families (DCF) and tell them about the change. Go to http://portal.flmmis.com/flpublic/Default.aspx and click the “Field Offices” tab to find the office near you. If your address has changed, please login to your My ACCESS Account and update your address. Log on to your “My ACCESS System” at https://myaccessaccount.dcf.state. fl.us/Login.aspx. You can also contact the ACCESS Customer Call Center toll-free at 1-866-762-2237. You must also contact the Social Security Administration toll-free at 1-800-772-1213 or visit the SSA website at http://www.ssa.gov/. 11. Be kind to everyone involved in your care. Be on time for your appointments. Call the doctor’s office if you cannot keep your appointment.
Your Rights and Protections as a Prestige Member Our teams treat all members equally. We do not discriminate. We follow the plan’s mission. We obey the law. Your rights include the following: 1. Being treated with dignity, respect, and having your privacy protected.
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2. Receiving care that is at least equal to service offered by similar health plans. 3. Receiving detailed information about emergency and after-hours options. Some details include: –– Emergency services do not require prior approval. –– You can use any hospital for emergency care.
–– Lists of emergency conditions. –– What to do after you have received emergency care.
4. Participating in decisions about your health care. You can ask about other available treatments. This includes the right to refuse treatment. 5. Being free from any form of limitations used to discipline, for convenience, or retaliation. 6. Talking to your PCP about family planning. These services are available without prior approval. The services are available from any Medicaid provider. 7. Being told about free translation services. We will arrange support for any language you speak. You’ll be told about free services for members with vision and hearing loss. You’ll receive the communication services you need to help make choices about your care. We can teach you more. Please call Member Services toll-free at 1-855-355-9800. For TTY, call at 1-855-358-5856. 8. Accessing the Notice of Privacy Practices. This tells when, why, and with whom we must sometimes share your Personal Health Information (PHI). 9. Seeing your Personal Health Information (PHI). 10. Having your privacy protected in accordance with the Health Insurance Portability and Accountability Act (HIPAA) requirement. 11. Seeing a list of the people who have asked to see your Personal Health Information (PHI). 12. Getting a copy of your Personal Health Information (PHI) in our records. 13. Requesting a copy of your medical records and that your Personal Health Information (PHI) be updated or corrected if there is an issue. 14. Receiving information about the grievance, appeal and Medicaid Fair Hearing process. We will arrange support for any language you speak. Receiving support from the State so that you have freedom to exercise your rights. This should not affect the way the health plan, and its providers or the State treat you. 15. Having health care services provided in accordance with both state and federal regulations. 16. Getting yearly updates about the disenrollment process. 17. Receiving updates on major changes in your benefits. You’ll be notified at least 30 days in advance. 18. Voicing a complaint or concern. Call Member Services toll-free at 1-855-355-9800 or TTY 1-855-358-5856. We will arrange support for any language you speak. Prestige Health Choice | 29
Protecting Your Privacy Your privacy is important to us. That’s why we take great care to make sure we use your personal information correctly and keep it safe. Your personal information can be oral, written or electronic and can come from your: Self,
Hospital,
Doctor,
Other health care providers.
There are certain ways we use your health information, keep it safe and share it with others. In general, we may use it to: Provide treatment,
Coordinate payment to other insurance companies,
Provide benefits,
Evaluate and improve our services.
Help your health team treat you and receive payment, We may also use and share your health information based on the law or Prestige policies. If you have questions about how we keep your information private, please call Member Services toll-free at 1-855-355-9800 or TTY 1-855-358-5856 for the hearing impaired. You can ask that we mail you a paper copy of the complete Notice of Privacy Practices. You can also see it by going to www.prestigehealthchoice.com.
Fraud and Abuse Prestige is committed to quality. But there may be times when you see fraud or abuse. Some examples of fraud and abuse by a health care provider are: Billing or charging you for services that Medicaid covers (other than co-pays).
Offering you free services, equipment or supplies in exchange for using your member number.
Offering you gifts or money to get treatment or services that you do not need.
Giving you treatment or services that you do not need. Physical, mental or sexual abuse by medical staff.
Some examples of fraud and abuse by a member are: Members selling or lending their ID cards to other people.
Members abusing their benefits by seeking drugs or services that are not medically-necessary.
To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll-free at 1-888-419-3456, or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at: https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx.
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If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program (toll-free 1-866-966-7226 or 850-414-3990). The reward may be up to twenty-five percent (25%) of the amount recovered, or a maximum of $500,000 per case (Section 409.9203, Florida Statutes).You can talk to the Attorney General’s Office about keeping your identity confidential and protected. You can also report fraud and abuse to Prestige. The Prestige Fraud Hotline number is toll-free 1-866-833-9718.
Other Abuse Prestige cares about you. If you are being abused, neglected or exploited please call the toll-free hotline, 1-800-96-ABUSE. There is no reason for physical, mental or sexual abuse.
Advance Directives People who are 18 years of age or older often make important choices about their health. State law lets you accept or refuse medical or surgical treatment. The law lets you pick someone to choose your care if you cannot. You can also say you want to make an organ donation. The form that states your choices is called an Advance Directive. If there are any changes in the law, we will let you know within 90 days of the change in the law. The best way to make sure your advance directive is followed is to write it down. You can download a form from www.floridahealthfinder.gov/reports-guides/advance-directives.aspx. Your Primary Care physician (PCP) will help you create an advance directive. Make sure you keep a copy and give a copy to your Primary Care Physician (PCP). Complaints about non-compliance with Advance Directive laws and regulations may be filed with the State’s AHCA complaint hotline at 1-888-419-3456.
Living Will A living will is a type of advance directive. You should always get help writing a living will. It needs to be very clear. Keep one copy in a safe place. Give the other copy to your primary care doctor. You can download a form from www.floridahealthfinder.gov/reports-guides/advance-directives.aspx.
Choosing a Health Care Surrogate Sometimes we need help making choices. Often we need that help when we are very sick. A health care surrogate is someone you pick to make health care choices for you. They can only make choices for you during the time you are too sick to make your own choices. You should pick someone you trust. Talk with them about your wishes. Make sure they understand what you want. Always get help writing a health care surrogate agreement. Be sure to include clear limits in the surrogate’s authority. If you need help appointing a health care surrogate visit www.floridahealthfinder.gov/reports-guides/advance-directives.aspx. If you feel there is a problem with your advance directive, you can file a complaint with the State. They run a compliance hotline. You can find more information at www.doh.state.fl.us. You can get help making an advance directive. We can teach you more. Please call Member Services toll-free at 1-855-355-9800.
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More about Prestige
Disenrollment If you are a mandatory enrollee and you want to change plans after the initial 90-day period ends or after your open enrollment period ends, you must have a state-approved good cause reason to change plans. The following are state-approved cause reasons to change health plans: 1. The enrollee does not live in a region where the Managed Care Plan is authorized to provide services, as indicated in FMMIS. 2. The provider is no longer with the Managed Care Plan. 3. The enrollee is excluded from enrolment. 4. A substantiated marketing or community outreach violation has occurred. 5. The enrollee is prevented from participating in the development of his/her treatment plan/plan of care. 6. The enrollee has received care for more than 6 months with a provider who is not on the Managed Care Plan’s panel, but is on the panel of another Managed Care Plan. 7. The enrollee is in the wrong Managed Care Plan as determined by the Agency. 8. The Managed Care Plan no longer participates in the region. 9. The state has imposed intermediate sanctions upon the Managed Care Plan, as specified in 42 CFR 438.702(a)(3). 10. The enrollee needs related services to be performed concurrently, but not all related services are available within the Managed Care Plan network, or the enrollee’s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk. 11. The Managed Care Plan does not, because of moral or religious objections, cover the service the enrollee seeks. 12. The enrollee missed open enrollment due to a temporary loss of eligibility. 13. Other reasons per 42 CFR 438.56(d)(2) and s. 409.969(2), F.S., including, but not limited to: poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; an unreasonable delay or denial of service; lack of access to providers experienced in dealing with the enrollee’s health care needs; or fraudulent enrollment. If you think you have a “good cause reason” for disenrollment, call a Medicaid Choice Counselor toll-free at 1-877-711-3662. Voluntary enrollees may disenroll from the Health Plan at any time. Some Medicaid recipients may change Managed Care Plans whenever they choose, for any reason. To find out if you may change plans, call the Enrollment Broker at 1-877-711-3662 or TTY users at 1-866-467-4970.
32 | Prestige Health Choice
Reasons Why You May be Disenrolled Reasons could be: 1. You let someone else use your Prestige ID card. 2. You act violent or threaten someone at Prestige. 3. You are no longer eligible for Medicaid. 4. You are admitted to a long-term care facility, hospice or go to prison. 5. You move out of the service area. 6. Death.
Grievances, Appeals, and Medicaid Fair Hearings Prestige is here to help you. If you are unhappy with the plan or with the care you have received you can call Member Services at 1-855-355-9800 for help.
Complaints You have the right to file a complaint with Prestige Health Choice. If we receive a complaint, we will try to resolve it by the end of the next business day. If we are unable to resolve your complaint, it will be moved into the Prestige grievance system within twenty-four (24) hours. Once in the grievance system, Prestige will determine if your complaint is a grievance or an appeal. A grievance is when you are unhappy with our plan or one of our providers. An appeal is when you are unhappy about a decision made by Prestige. This is usually if Prestige decides to deny, limit, reduce, suspend, or stop any service. If you want to appeal, Prestige will review the decision again.
Grievances If you want to file a grievance, call Member Services toll free at 1-855-355-9800. We will help you understand the process and arrange support for any language you speak. A grievance must be filed within one (1) year from the event that made you unhappy. You can also write a letter to tell us about your grievance. Anybody you trust can help you write the letter. Our address is: Prestige Health Choice PO Box 7366 London, KY 40742 Prestige will mail you a letter within five (5) business days to let you know we have received your grievance. You can ask us to extend the review time for your grievance for up to fourteen (14) days. Call Member Services at 1-855-355-9800 to let us know. Prestige Health Choice | 33
If Prestige decides we need more time to review your grievance, we will let you know in writing within five (5) business days. We will tell you the reason why we need more time to review your grievance.
While we review your grievance, we will do the following: Allow you to give us any information that you feel will be helpful to us in making a decision. Call you if we need more information. Let you review any medical/case records and other material being reviewed. Explain to you all time frames related to your grievance. Prestige will make a decision on your grievance within ninety (90) days from the day we receive it.
We will mail you a notice (letter) with the following: Our decision. The date the decision was made. How to request a Medicaid Fair Hearing. How to appeal our decision through the Subscriber Assistance Program (SAP).
Appeals If you are unhappy with the decision made by Prestige, you can ask us to look at the decision again. This is an appeal. You must file your appeal within thirty (30) days from the date on the notice (letter) you receive. You may file your appeal by phone or in writing. If you file your appeal by phone, you must send us a written notice within ten (10) days of your phone call. We will use the date of your phone call as the start date for your appeal. Our address is: Prestige Health Choice PO Box 7368 London, KY 40742 Our fax is 1-855-358-5847 You can continue receiving services while we review your appeal. You may have to pay for services if your appeal is denied. You can ask for us to extend the review time for your appeal by up to fourteen (14) days. Call Member Services at 1-855-355-9800 to let us know. If Prestige decides we need more time to review your appeal, we will let you know in writing within five (5) business days. We will tell the reason why we need to extend the review time.
34 | Prestige Health Choice
While we review your appeal, we will do the following: Allow you to give us any information that you feel will be helpful to us in making a decision. Call you if we need more information. Let you review any medical/case records and other material being reviewed. Explain to you all time frames related to your appeal. We will make a decision on your appeal within forty-five (45) days from the day we receive it. If you need the decision faster, you can ask for an expedited (fast) appeal. See below for details.
We will mail you a notice (letter) with the following: Our decision. The date the decision was made. How to request a Medicaid Fair Hearing. How to appeal our decision through the Subscriber Assistance Program (SAP).
Expedited Appeals An expedited (fast) appeal is what you request when you or your PCP thinks your health is at risk, and you need an answer quickly. Prestige will review and resolve each expedited (fast) appeal within three (3) business days from the day we receive the request.
Appealing to the Subscriber Assistance Program If you have completed the Prestige appeal process and you are still unhappy, you can appeal to the Subscriber Assistance Program (SAP). The SAP is a committee run by the State of Florida. You must complete the appeal process with Prestige before you can submit your appeal to the SAP. You must submit your appeal to the SAP within one (1) year after getting the decision notice (letter) from Prestige. If you have already had gone through a Medicaid Fair Hearing, then you cannot appeal to go through the SAP. You can submit your appeal with the SAP by writing to: Agency for Health Care Administration Subscriber Assistance Program Building 3, MS #45 2727 Mahan Drive Tallahassee, Florida 32308 You can call also call the SAP at 1-850-412-4502 or 1-888-419-3456.
Prestige Health Choice | 35
Medicaid Fair Hearing You can ask for a Medicaid Fair Hearing. An independent officer at the Department of Children and Families conducts a Medicaid Fair Hearing. With your written approval, you can choose someone to speak for you at the Medicaid Fair Hearing. The hearing officer will make a decision based on rules and regulations, the facts produced during the hearing, and post-hearing submissions. A decision from a Medicaid Fair Hearing is final, and can not be appealed. You can ask for a Medicaid Fair Hearing if you have gone through the Prestige grievance and appeal process. You must request a fair hearing within ninety (90) days from the date on the notice (letter) of resolution for your appeal. You can also ask for a Medicaid Fair Hearing if you have not submitted a grievance and appeal with Prestige. You can request a Medicaid Fair Hearing by writing to: Department of Children and Families Office of Appeal Hearings Building 5, Room 255 1317 Winewood Boulevard Tallahassee, FL 32399-0700 You can also request a Medicaid Fair Hearing by: calling 1-850-488-1429 faxing 1-850-487-0662 or email
[email protected] For more information visit http://www.myflfamilies.com/about-us/office-inspector-general/investigationreports/appeal-hearings.
36 | Prestige Health Choice
Important Telephone Numbers Your Personal Guide to Better Health – List of Helpful Numbers Prestige Member Services:
1-855-355-9800 / TTY 1-855-358-5856
Enrollment Services/Medicaid Choice Counseling:
1-877-711-3662 / TTY 1-866-467-4970
Florida’s Department of Children and Families:
1-866-762-2237
FL Medicaid Consumer Complaint Hotline:
1-888-419-3456
Prestige Nurse Call Line:
1-855-398-5615
Prestige Rapid Response and Outreach Team:
1-855-371-8072
Prestige Behavioral Health Provider:
1-855-371-3967
Prestige Fraud Hotline:
1-866-833-9718
Prestige Pharmacy Member Services:
1-855-371-3963
My Prestige Member Number is:________________________________________________________________ Other Family Members’ Prestige ID Numbers are: ___________________________________________
___________________________________________
___________________________________________
___________________________________________
My PCP/Medical Home: ______________________________________________________________________ My Child’s PCP/Medical Home:_________________________________________________________________ My Prestige Care Manager:____________________________________________________________________
Prestige Health Choice | 37
HEALTH CHOICE ®
PRES-1422-01 M1001_1501
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/TDD 1-855-358-5856, las 24 horas d el día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7.
Thank you for choosing Prestige Health Choice. RE: Enrollment Update Dear Member: We are pleased that you have chosen Prestige Health Choice as your health plan. If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Prestige or the state enrolls you in a plan, you will have 120 days* from the date of your first enrollment to try the Managed Care Plan. During the first 120 days you can change Managed Care Plans for any reason. After the 120 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next eight months. Please refer to the Member Handbook for information about benefits and services. For a list of Prestige providers, go to our website at www.prestigehealthchoice.com. We’re here to help you. If you have questions, call Member Services at any time. The toll-free number is 1-855-355-9800. Thank you for choosing Prestige Health Choice. Sincerely, Prestige Member Services
*This is an update from the “Enrollment” content stated on page 3 of the Member Handbook.
Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/TDD 1-855-358-5856, las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7.
ML1211_1511
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week.
Zika Virus and Pregnancy
Zika virus is a disease you can get from being bitten by a mosquito carrying the virus or from having unprotected sex with an infected person. Zika virus may make you feel like you have the flu. The most common symptoms are fever, rash, joint aches, pink eye, and headache. It can take up to 2 weeks for a person with Zika virus to notice any symptoms. A blood test is the only way to confirm that someone has the virus. Not all mosquitoes carry Zika virus. A pregnant woman who has Zika virus can spread the virus to her baby. Serious birth defects have been reported in babies born to women who had Zika virus during pregnancy: • Microcephaly (abnormal smallness of the head associated with incomplete brain development). • Other severe brain defects. • Eye defects. • Hearing loss. • Impaired growth. If you are planning to have a baby and you have been diagnosed with Zika virus or have symptoms of Zika virus, the Centers for Disease Control and Prevention (CDC) recommends: • You call your health care provider. • Women wait at least 8 weeks after their symptoms first appeared before trying to get pregnant. • Men wait at least 6 months after their symptoms first appeared to have unprotected sex. The Zika virus lives longer in semen than in blood. • Both men and women who have been exposed to Zika virus, but have not had the Zika infection, wait at least 8 weeks before having unprotected sex. • Women use contraception to avoid Zika-related pregnancy complications. If you are pregnant and have symptoms or have been exposed to the Zika virus, call your health care provider right away.
HEALTH CHOICE ®
Zika Virus and Pregnancy More cases of Zika virus are showing up in the United States. That’s why everyone needs to know about the potential danger. If you already pregnant: • Avoid or delay traveling to areas where there is active Zika virus transmission. • Protect yourself from mosquito bites. Use insect repellant or wear long-sleeved shirts and long pants. • Prevent transmission if your partner has been exposed by using condoms or not having sex during pregnancy. Prestige Health Choice covers several over-the-counter (OTC) insect repellant products. See the table below for products that are included in our expanded OTC benefits list.
Product name
Ounces
UPC
OFF! Family Care
2.5 oz.
46500710377
OFF! Deep Woods
4 oz.
46500717642
OFF! Deep Woods
6 oz.
46500018248
OFF! Active
6 oz.
46500018107
Cutter Skinsations
6 oz.
16500540106
Cutter Backwoods
6 oz.
71121962805
Repel Insect Sportsmen
6.5 oz.
11423941375
Repel Sportsmen Max Formula
6.5 oz.
11423003387
Coverage of OTC medicine is limited to $25 per month, per household, with a maximum of $50 per year.
Talk to your health care provider if you have any questions about your health. If you are pregnant, you can also call Bright Start®, the Prestige Health Choice maternity program, at 1-855-371-8076, Monday through Friday, 8 a.m. – 5 p.m. Visit www.cdc.gov/zika for the most up-to-date information about Zika virus.
HEALTH CHOICE ®
EWM-16213
www.prestigehealthchoice.com
We will help you find a provider near you. RE: Provider Directory Dear Member: We are pleased that you have chosen Prestige Health Choice as your health plan. We are committed to our partnerships to make sure you get the care you need. As a member, you have access to our most current listing of doctors, hospitals, pharmacies, and other providers. Here are the ways you can find a Prestige provider near you: Online Searchable Provider Directory - If you would like to find information about Prestige providers online, visit www.prestigehealthchoice.com and click on “self-service tools” under the member tab to begin your search. Printed Provider Directory – If you would like to receive a printed paper copy of the current Provider Directory, you can call Member Services at 1-855-355-9800 (TTY/TDD 1-855-3585856) and we will send one to you. We’re here to help you. If you have questions or need help finding a Prestige provider, call Member Services at any time. The toll-free number is 1-855-355-9800. Thank you for choosing Prestige Health Choice. Sincerely,
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/TDD 1-855-358-5856, las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7.
ML1201_1507
Prestige Member Services
Please read this letter! It is important. RE: Transfer medical records to your new doctor
Dear Member: If you plan to change your doctor, Prestige Health Choice can help you ask for your medical records from your old doctor. You need to approve the release of your medical records from your old doctor to your new one. You will find a Universal Patient Authorization for Full Disclosure of Health Information for Treatment and Quality of Care Form in your welcome package. This form gives your old doctor permission to send your records to your new doctor. Please read and sign the form. Take the form to the doctor who was treating you. Your old doctor will send your medical records to your new doctor. Your new doctor will have access to your medical records. If you have any questions, call Member Services at any time. The toll-free number is 1-855-355-9800.
Thank you for choosing Prestige Health Choice. Sincerely, Prestige Member Services
PRES-1422-06 ML1005_1401
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/ TDD 1-855-358-5856, las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7.
UNIVERSAL PATIENT AUTHORIZATION FORM FOR FULL DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT AND QUALITY OF CARE ***PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW*** Patient (name and information of person whose health information is being disclosed): Name (First Middle Last): Date of Birth (mm/dd/yyyy): Address:
City:
State:
Zip:
You may use this form to allow your healthcare provider to access and use your health information. Your choice on whether to sign this form will not affect your ability to get medical treatment, payment for medical treatment, or health insurance enrollment or eligibility for benefits.
By signing this form, I voluntarily authorize, give my permission and allow use and disclosure: OF WHAT:
ALL MY HEALTH INFORMATION including any information about sensitive conditions (if any) [See page 2 for details]
FROM WHOM:
ALL information sources [See page 2 for details]
TO WHOM: Specific person(s) or organization(s) permitted to receive my information (must be a healthcare provider): Person/Organization Name:
Phone: (
Address:
Fax: (
) )
PURPOSE: To provide me with medical treatment and related services and products, and to evaluate and improve patient safety and the quality of medical care provided to all patients. EFFECTIVE PERIOD: This authorization/permission form will remain in effect until my death or the day I withdraw my permission. REVOKING MY PERMISSION: I can revoke my permission at any time by giving written notice to the person or organization named above in “To Whom.” In addition: • I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above. • I understand that there are some circumstances in which this information may be redisclosed to other persons [See page 2 for details]. • I understand that refusing to sign this form does not stop disclosure of my health information that is otherwise permitted by law without my specific authorization or permission. • I have read all pages of this form and agree to the disclosures above from the types of sources listed.
X_____
Signature of Patient or Patient’s Legal Representative
Date Signed (mm/dd/yyyy)
_____
Print Name of Legal Representative (if applicable) Check one to describe the relationship of Legal Representative to Patient (if applicable): Parent of minor Guardian Other personal representative (explain:
)
NOTE: This form is invalid if modified. You are entitled to get a copy of this form after you sign it.
Form Florida AHCA FC4200-004 (July 1, 2011)
59B-16.002, F.A.C.
Page 1 of 2
www.FHIN.net
Explanation of Form Florida AHCA FC4200-004 “Universal Patient Authorization for Full Disclosure of Health Information for Treatment & Quality of Care” Laws and regulations require that some sources of personal information have a signed authorization or permission form before releasing it. Also, some laws require specific authorization for the release of information about certain conditions and from educational sources. “Of What”: includes ALL YOUR HEALTH INFORMATION, INCLUDING: 1. All records and other information regarding your health history, treatment, hospitalization, tests, and outpatient care. This information may relate to sensitive health conditions (if any), including but not limited to: a. Drug, alcohol, or substance abuse b. Psychological, psychiatric or other mental impairment(s) or developmental disabilities (excludes “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501) c. Sickle cell anemia d. Birth control and family planning e. Records which may indicate the presence of a communicable disease or noncommunicable disease; and tests for or records of HIV/AIDS or sexually transmitted diseases or tuberculosis f. Genetic (inherited) diseases or tests 2. Copies of educational tests or evaluations, including Individualized Educational Programs, assessments, psychological and speech evaluations, immunizations, recorded health information (such as height, weight), and information about injuries or treatment. 3. Information created before or after the date of this form. “From Whom” includes: All information sources including but not limited to medical and clinical sources (hospitals, clinics, labs, pharmacies, physicians, psychologists, etc.) including mental health, correctional, addiction treatment, Veterans Affairs health care facilities, state registries and other state programs, all educational sources that may have some of my health information (schools, records administrators, counselors, etc.), social workers, rehabilitation counselors, insurance companies, health plans, health maintenance organizations, employers, pharmacy benefit managers, worker’s compensation programs, state Medicaid, Medicare and any other governmental program. “To Whom”: For those health care providers listed in the “TO WHOM” section, your permission would also include physicians, other health care providers (such as nurses) and medical staff who are involved in your medical care at that organization’s facility or that person’s office, and health care providers who are covering or on call for the specified person or organization, and staff members or agents (such as business associates or qualified services organizations) who carry out activities and purpose(s) permitted by this form for that organization or person that you specified. Disclosure may be of health information in paper or oral form or may be through electronic interchange. “Purpose”: Your signature on this form does NOT allow health insurers to have access to your health information for the purpose of deciding to give you health insurance or pay your bills. You can make that choice in a separate form that health insurers use. “Revocation”: You have the right to revoke this authorization and withdraw your permission at any time regarding any future uses by giving written notice. This authorization is automatically revoked when you die. You should understand that organizations that had your permission to access your health information may copy or include your information in their own records. These organizations, in many circumstances, are not required to return any information that they were provided nor are they required to remove it from their own records. “Re-disclosure of Information”: Any health information about you may be re-disclosed to others only to the extent permitted by state and federal laws and regulations. You understand that once your information is disclosed, it may be subject to lawful re-disclosure, in accordance with applicable state and federal law, and in some cases, may no longer be protected by federal privacy law. Limitations of this Form: If you want your health information shared for purposes other than for treating you or you want only a portion of your health information shared, you need to use Form Florida AHCA FC4200-005 (Universal Patient Authorization Form For Limited Disclosure of Health Information), instead of this form. Also, this form cannot be used for disclosure of psychotherapy notes. This form does not obligate your health care provider or other person/organization listed in the “From Whom” or “To Whom” section to seek out the information you specified in the “Of What” section from other sources. Also, this form does not change current obligations and rules about who pays for copies of records.
Form Florida AHCA FC4200-004 (July 1, 2011)
59B-16.002, F.A.C.
Page 2 of 2
www.FHIN.net
Dear Member:
SUBJECT: Continuity of Care Notice
Welcome to Prestige Health Choice. We want to help you get the best care and service possible. You may be seeing a doctor that is not part of the Prestige network. We will work to help you continue your current care until you meet with your Prestige doctor. This is called your “Continuity of Care” time. It is the first sixty (60) days with us. Your “Continuity of Care” time ends sixty (60) days after your start date. You can see your start date on your Prestige ID card. It is important that you make an appointment with your primary Prestige doctor and talk about the care you had before you joined Prestige. You and your Prestige doctor may talk about the care you need in the future. Your doctor’s information is on your Prestige ID card. Please make an appointment with your assigned doctor in the next thirty (30) days to discuss your care. You may call Rapid Response if you have any questions at 1-855-371-8072. Sincerely, Prestige Health Choice
PRES-1422-09 ML1146_1401
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/TDD 1-855-358-5856, las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7.
How and Where to Get Care Get Care Now
Call First
Is it an emergency?
Yes
Get Care Quickly (within 24 hours)
Get Care Soon
CALL 911 for problems like:
Chest pain Choking Poisoning Severe wound/heavy bleeding Not able to breathe right Severe spasms/convulsions Loss of speech Broken bones Severe burns
Drug overdose Sudden loss of feeling or not being able to move Severe dizzy spells, fainting or blackouts
Before going to the emergency room: I don’t know
No
Please call your doctor or the 24/7 Nurse Call Line at 1-855-398-5615.
Do you need urgent care? Yes
Call your doctor or the 24/7 Nurse Call Line for problems like:
Coughing Vomiting Diarrhea Sore throat Colds Pink eye Stomach ache
Rashes Bruises
www.prestigehealthchoice.com
Toothache - call your dentist or Member Services if you don’t have a dentist.
No
Call your doctor or the 24/7 Nurse Call Line for problems like:
Toothache Sunburn Skin rash Sexually Transmitted Disease (STD) Earache Sprains Animal or insect bite Fever Minor cuts
Dear Member:
Thank you for choosing Prestige Health Choice as your health plan. We want you to have the best care. To help with your care, we need to make sure we have the right contact info for you. Please complete the form on the back of this letter, or call Prestige Health Choice at 1-855-355-9800 to speak to one of our Member Services Representatives if you’ve changed your: Name Mailing address Home address County where you live Telephone number (Please list all numbers where we can reach you.) Email (Optional) You should also update your contact information with the following agencies: Department of Children and Families 1-866-762-2237 Social Security Administration 1-800-772-1213 If you complete the contact form, mail it to: Prestige Health Choice PO Box 7181 London, KY 40742 Sincerely, Prestige Member Services Department
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/ TDD 1-855-358-5856, las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7.
Prestige Health Choice Member Contact Form First Name: Last Name: Home Address: State:
Zip Code:
City:
State:
Zip Code:
Telephone Number:
Alternate Number:
City: County: Mailing Address:
Email Address: Telephone Number:
PRES-1422-07 ML1003_1401
Email Address:
Initial Health Screening Questionnaire CONTACT INFORMATION First Name:_______________________________ M.I.:________ Last Name:_______________________________ Address:______________________________________________________________________________________ City:___________________________________________ State:____________Zip Code:______________________ Phone (Best number to reach you):_____________________________________ Date of birth:_____________________ LANGUAGE PREFERENCES What language is most comfortable for you to speak about your health? qq English
qq Somali
qq Spanish
qq Arabic
qq Bosnian
qq Russian
qq French
qq German
qq Vietnamese
qq Other: _________________________________________________________________________________________________________________ What language is most comfortable for you to read about your health? qq English
qq Somali
qq Spanish
qq Arabic
qq Bosnian
qq Russian
qq French
qq German
qq Vietnamese
qq Other: _________________________________________________________________________________________________________________ ETHNICITY AND RACE What is your ethnicity? qq Hispanic
If Hispanic or Latino, what is your Country of Origin?___________________________________
qq Non-Hispanic qq Other:___________________________________________________________________________________ How do you describe your race? qq American Indian or Alaskan Native
qq Black/African American
qq Middle Eastern/North African
qq Asian
qq Native Hawaiian Pacific Islander
qq White/Caucasian
qq Decline to State
qq Other:_____________________________________
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/TDD 1-855-358-5856, las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7.
1. Who is completing the survey? qq Member
qq Parent/Guardian
qq Other
qq Name of Parent/Guardian or Other___________________________________________________________ 2. Are you pregnant?
q Yes
q No
3. In general, would you say your health is: qq Excellent
qq Good
qq Very Good
qq Fair
qq Poor
4. Do you or your child have any illnesses? qq Asthma
qq Behavioral Health
qq Diabetes
qq Sickle Cell Disease
qq High Blood Pressure or Cholesterol
qq ADHD
qq Seizures / Convulsions
qq Other:__________________________________
5. Are you (or your child) having a problem getting in to see your doctor or specialist for a visit? q Yes
q No
q Don’t have a doctor that I see regularly
6. What type of transportation do you (or your child) usually use for medical appointments or services? qq Drive myself
qq Ambulance
qq Taxi
qq No reliable means
qq Caregiver/friend
qq Other:__________________________________
qq Public Transportation 7. Do you (or your child) take any medications?
q Yes
q No
8. If Yes - Do you (or your child) need help getting your medications?
q Yes
q No
9. Do you (or your child) use any tobacco products? qq No
qq Smokeless Tobacco (Chewing Tobacco)
qq Cigarettes or Cigars 10. Are you (or your child) around people who smoke tobacco products?
q Yes
q No
11. Do you (or your child) have any problems with walking, bathing, dressing or using the toilet?
q Yes
q No
12. Do you (or your child) use any medical equipment?
q Yes
q No
13. If Yes - Do you (or your child) need assistance in getting equipment, supplies or home care items? q Yes 14. Are you (or your child) currently receiving any Mental Health Services?
q Yes
q No
15. Would you (or your child) like to receive assistance with Mental Health Services?
q Yes
16. Do you (or your child) see a dentist?
q Yes
q No
q No
q No
17. Do you feel that your (or your child’s) illness or condition is not under control? 18. Do you need help with food, clothing or housing?
q Yes
q Yes
q No
q No
Thank you for completing our health questionnaire! This information will help us provide you with the best possible care. Please return this form in the postage paid return envelope or send to:
Prestige Health Choice PO Box 7181 London, KY 40742
You may also fax the completed form to 1-855-236-9281. If you have any questions concerning this form, please call Member Services at 1-855-355-9800.
PRES-1422-05 M1012_1401
Discrimination is against the law
La discriminación está en contra de la ley
Prestige Health Choice complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Prestige does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Prestige Health Choice cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, origen nacional, edad, discapacidad o sexo. Prestige no excluye a las personas ni las trata de modo diferente debido a su raza, color, origen nacional, edad, discapacidad o sexo. Prestige: • Proporciona a las personas con discapacidades, para que puedan comunicarse con nosotros eficazmente, asistencia y servicios gratuitos, tales como: -- Intérpretes calificados del lenguaje de señas. -- Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos). • Proporciona servicios sin cargo a personas cuyo idioma principal no es el inglés, por ejemplo: -- Intérpretes calificados. -- Información escrita en otros idiomas. Si necesita estos servicios, llame a Prestige al 1-855-355-9800 (TTY 1-855-358-5856). Estamos disponibles las 24 horas del día, los 7 días de la semana. Si cree que Prestige no ha provisto estos servicios o ha discriminado de otra manera en función de raza, color, origen nacional, edad, discapacidad o sexo, usted puede presentar una queja formal dirigida a: • Grievance and Appeals, PO Box 7368, London, KY 40742. 1-855-371-8078 (TTY 1-855-371-8079), Fax: 1-855-358-5847. • Puede presentar una queja formal por correo postal, fax o teléfono. Si necesita ayuda para presentar una queja formal, Servicios al Miembro de Prestige está disponible para ayudarlo. También puede presentar una queja relativa a los derechos civiles ante el Departamento de Salud y Servicios Humanos de los EE.UU., Oficina de Derechos Civiles (en inglés, U.S. Department of Health and Human Services, Office for Civil Rights) de manera electrónica a través del Portal de Quejas sobre Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/ portal/lobby.jsf, o por correo postal o teléfono a: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Los formularios de quejas están disponibles en: http://www.hhs.gov/ocr/office/file/index.html.
Prestige: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: -- Qualified sign language interpreters. -- Written information in other formats (large print, audio, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as: -- Qualified interpreters. -- Information written in other languages. If you need these services, contact Prestige at 1-855-355-9800 (TTY 1-855-358-5856). We are available 24-hours, 7 days a week. If you believe that Prestige has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: • Grievance and Appeals, PO Box 7368, London, KY 40742. 1-855-371-8078 (TTY 1-855-371-8079), Fax: 1-855-358-5847. • You can file a grievance by mail, fax, or phone. If you need help filing a grievance, Prestige Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/ portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html.
Zak diskriminasyon ann amoni lalwa Zak diskriminasyon papa ann amoni akak lalwa
Multi-language interpreter interpreter services services Multi-language
Prestige Health Choice dakò ak lwa federal yo epi pa fè Prestige Health Choice dakò ak lwa federal sousou dwadwa sivilsivil yo epi li pali fè diskriminasyon koulè, kote w soti, andikap oswa diskriminasyon sousou bazbaz ras,ras, koulè, peyipeyi kote w soti, laj, laj, andikap oswa sèks ou. Prestige mete kote oswa tretelòt moun lòt jan ras,peyi ou.sèks Prestige pa metepa sou kotesou oswa trete moun jan akoz ras,akoz koulè, koulè, peyi kote w soti, laj, andikap oswa sèks ou. kote w soti, laj, andikap oswa sèks ou. Prestige: Prestige: • Bay moun ki gen andikap asistans ak sèvis gratis pou kominike • Bayfasilman moun kiak gen andikap asistans ak sèvis gratis pou kominike nou, tankou: fasilman ak nou, tankou: - Entèprèt konpetan nan lang siy. -- Entèprèt konpetan nan lang siy. - Enfòmasyon sou lòt fòma (gwo karaktè, odyo, fòma -- Enfòmasyon lòt fòma elektwoniksou aksesib, lòt (gwo fòma karaktè, ankò). odyo, fòma elektwonik aksesib, lòt fòma ankò). • Bay moun ki pa fò nan anglè sèvis lang gratis, tankou: • Bay moun ki pa fò nan anglè sèvis lang gratis, tankou: - Entèprèt konpetan. -- Entèprèt konpetan. - Enfòmasyon ki ekri nan lòt lang. -- Enfòmasyon ki ekri nan lòt lang. Si w ta bezwen youn nan asistans sa yo, kontakte Prestige nan Si w1-855-355-9800 ta bezwen youn(TTY nan asistans sa yo, kontakte 1-855-358-5856). Nou Prestige disponibnan 7 jou sou 7 epi 1-855-355-9800 (TTY 1-855-358-5856). Nou disponib 7 jou sou 7 epi 24 24 sou 24. sou 24. Si w ta konstate Prestige neglije bay sèvis sa yo oswa fè diskriminasyon sou baz ras, koulè, peyi soti, laj, andikap oswa sèks, ou Si wkèlkonk ta konstate Prestige neglije baykote sèviswsa yo oswa fè diskriminasyon ka depoze yonras, doleyans nan:kote w soti, laj, andikap oswa sèks, ou ka kèlkonk sou baz koulè, peyi depoze doleyansand nan: • yon Grievance Appeals, PO Box 7368, London, KY 40742. 1-855-371-8078 (TTY 1-855-371-8079), Faks: 1-855-358-5847. • Grievance and Appeals, PO Box 7368, London, KY 40742. •1-855-371-8078 Ou ka depoze (TTY yon doleyans pa mwayenFaks: imèl,1-855-358-5847. faks, oswa telefòn. 1-855-371-8079), Si w gen difilte pou w depoze yon doleyans, yon Manm nan Si w • Ou ka depoze yon doleyans pa mwayen imèl, faks, oswa telefòn. Sèvis Prestige la ap kontan ede w. gen difilte pou w depoze yon doleyans, yon Manm nan Sèvis Prestige Oulakaappote yon ede plent kontan w.sou dwa sivil bay Depatman Sante ak Sèvis Dwa Moun Etazini an ak Biwo Dwa Sivil la pa mwayen elektwonik, ou ka fè Ou ka pote yon plent sou dwa sivil bay Depatman Sante ak Sèvis Dwa Moun sa sou Paj pou Plent Biwo pou Dwa Sivil la nan https://ocrportal.hhs. Etazini an ak Biwo Dwa Sivil oswa la pa mwayen elektwonik, ou ka fè sa sou gov/ocr/portal/lobby.jsf, pa mwayen kourye oswa telefòn nan:Paj pou Plent Biwo pou Dwa Sivil la nan https://ocrportal.hhs.gov/ocr/portal/ U.S. Department of Health and Human Services lobby.jsf, oswa pa mwayen kourye oswa telefòn nan: 200 Independence Avenue, SW 509F, HHH Building U.S.Room Department of Health and Human Services D.C. 20201 SW 200Washington, Independence Avenue, Room 509F, HHH Building 1-800-368-1019, 800-537-7697 (TDD) Washington, D.C. 20201 Fòmilè pou plent yo disponib nan: http://www.hhs.gov/ocr/office/file/index.html. 1-800-368-1019, 800-537-7697 (TDD)
English: ATTENTION: If you speak English, language assistance services, free of charge [at no cost], are available to you. Call 1-877-430-5638.
Fòmilè pou plent yo disponib nan: http://www.hhs.gov/ocr/office/file/index.html.
PRES-16218 PRES-16218
www.prestigehealthchoice.com www.prestigehealthchoice.com
Spanish: ATENCIÓN: Si usted habla español, tiene a su disposición servicios de asistencia lingüística de forma gratuita [sin costo]. Llame al 1-877-430-5638. Haitian Creole: ATANSYON: Si w pale Kreyòl ayisyen, ou kapab jwenn sèvis ki gratis [san sa pa koute w anyen] pou ede w nan lang pa w. Rele nan 1-877-430-5638. Arabic: .) فإن خدمات المساعدة اللغوية تتوافر لك بالمجان (بدون تكلفة، إذا كنت تتحدث اللغة العربية:ملحوظة .1-877-430-5638 اتصل برقم Chinese Mandarin: 注意：如果您说中文普通话/国语，我们可为您提供免费 语言援助服务[无需付费]。请致电：1-877-430-5638。 Chinese Cantonese: 注意：如果您使用粵語，您可以免費獲得語言援助服務 [無需付費]。請致電 1-877-430-5638。 Syriac:
Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí [không mất tiền] dành cho bạn. Gọi số 1-877-430-5638. Albanian: VINI RE: Nëse flisni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë [pa asnjë shpenzim nga ana juaj]. Telefononi në 1-877-430-5638. Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 비용 부담 없이[무료로] 이용하실 수 있습니다. 1-877-430-5638 번으로 전화해 주십시오. Bengali: লক্ষ্য করুনঃ আপনন যনি বাংলায় কথা বললন তাহলল নবনামূললষ্য [ননঃখরচায়] ভাষা সহায়তা পনরলষবা পালবন। এর জনষ্য 1-877-430-5638 নম্বলর ফ�ান করুন। Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej [bez żadnych kosztów] pomocy językowej. Zadzwoń pod numer 1-877-430-5638. German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen gebührenfrei (kostenlos) sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-430-5638. French: ATTENTION : si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement [sans coût]. Appelez le 1-877-430-5638. Japanese: 注意事項：日本語を話される場合、 言語支援フリーサービス（無料）をご利用いただけます。 1-877-430-5638まで、お電話にてご連絡ください。 Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные [на безвозмездной основе] услуги перевода. Звоните 1-877-430-5638. Serbo-Croatian: PAŽNJA: Ako govorite srpsko-hrvatski, na raspolaganju su vam besplatne usluge tumača [bez naplate]. Nazovite 1-877-430-5638. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari mong mapakinabangan ang libreng [walang bayad] language assistance service (pag gabay sa wikang Tagalog). Tumawag sa 1-877-430-5638.
Notice of Privacy Practices
Effective May 1, 2012 (Revised January 5, 2015)
HEALTH CHOICE ®
This notice explains how medical information about you may be used and shared, and how you can get access to this information. Please read it carefully.
Our responsibilities We are required by law to maintain the privacy and We must follow the privacy practices of the notice security of your protected health information (PHI). that is currently in effect and give you a copy of it. We have the right to change our privacy practices. We will let you know promptly if a breach occurs If there is a material revision to our privacy that may have compromised the privacy or security practices, you will receive a notice within 60 days of your information. of the change. The new notice will also be available We will not use or share your information other on our website at www.prestigehealthchoice.com. than as described here unless you tell us we can We also have the right to apply the changes to in writing. If you tell us we can, you may change PHI we already have, as well as PHI we create or your mind at any time. Let us know in writing if receive in the future. you change your mind.
How we use or share PHI When you are enrolled in Prestige, we maintain a record of that enrollment. We send you a welcome kit, an identification card and notify you of the primary care physician (PCP) you are assigned to for routine care. We maintain information sent by the medical practitioners who provide services to you as a Prestige member. We keep records necessary to comply with federal and state regulations. We keep records to help make sure you receive appropriate care and to make determinations about your coverage and treatment under Prestige. We keep track of some of your calls to Prestige and correspondence between you and Prestige. Under federal law we may use and/or disclose this information for treatment, payment or operations, including to: Plan your care and treatment. Assess recognized standards of care that may apply to you and notify your PCP and other providers in our network of those recommendations. Communicate with other health professionals involved in your care. Document the care you receive. Coordinate coverage you may have with other insurance companies or payers, such as Medicare.
Clarify your enrollment status with Florida Medicaid and Florida Healthy Kids. Provide information to public health officials. Evaluate and improve the care we provide. Notify medical providers in our network of your enrollment and coverage with Prestige. Manage payments to providers for the care they provide. Monitor possible fraud and abuse, and to comply with federal and state fraud and abuse initiatives.
However, under Florida law “medical records may not be furnished to, and the medical condition of a patient may not be discussed with, any person other than the patient or the patient’s legal representative or other health care practitioners and providers involved in the care or treatment of the patient, except upon written authorization of the patient.” (Fla. Stat. 456.057(7)(a)). Since Florida law is more restrictive, we must follow it with regard to the disclosure of medical records.
We must use and share your PHI if asked by: You or your legal representative. The secretary of the Department of Health and Human Services to make sure your privacy is protected. We have the right to use and share PHI for treatment, payment and health care operations. For example, we may use and share PHI: To pay premiums, determine coverage and process claims. For example, we may tell a doctor you have coverage or how much of the bill will be covered. For treatment or care management. For example, we may share your PHI with providers to help them give you care. For health care operations. We may use and share your PHI in the process of running our health care operations. For example, we may suggest a disease management program.
To tell you about health programs or products. This may be other treatments, services or products. For reminders on benefits or care. For example, we may send you appointment reminders. To resolve grievances and appeals. For example, we may use and share your PHI during the investigation of a grievance or an appeal.
We may use or share your PHI: As required by law. We will use and share your PHI when required by federal, state or local law. With persons involved with your care. This may happen if you are unable to agree or object, such as in an emergency or when you fail to object when asked. For health oversight activities. We may share PHI with an agency allowed by the law to get PHI. This may be for licensure, audits and fraud and abuse investigations. For judicial or administrative proceedings, such as to answer a court order or subpoena.
For law enforcement. We may share PHI if requested by a law enforcement official to respond to a court order, warrant, subpoena, summons, investigative demand or similar process. For serious threats to health or safety. This may be to public health agencies or law enforcement, such as in an emergency or disaster, to help prevent or lessen the threat. For medical issues, such as to respond to organ and tissue donation requests and work with a medical examiner or funeral director.
Use and sharing of highly confidential PHI may be limited by federal or state laws. If stricter laws apply, we try to meet those laws. We do not use or share your PHI without written consent, except as stated in this document. If you allow us to share your PHI, we do not promise that the person who gets it will not share it. You may take back your consent at any time, unless we have acted on it. To find out how to take back your consent, please call Prestige Member Services at 1-855-355-9800. Website use: When you visit the Prestige Health Choice website, you may have the opportunity to link to other websites. Please be aware that we do not have access, control, input or authorization over any materials or content at these websites. In addition, we are not responsible for, and do not endorse, the privacy practices, content or policies of any of these other websites.
Member rights You have the following rights: To request restriction on certain uses and sharing of your PHI. We are not required to agree to a requested restriction. To receive confidential communications of PHI. To inspect and copy your PHI. Note that Prestige is not the author of your clinical records, which are maintained by your PCP and the various medical providers in our network who provide treatment. To correct your health and claims records if you think they are incorrect or incomplete. We may say “no” to your request, but we will tell you why in writing within 60 days. To receive a list of those with whom your PHI has been used or shared other than for treatment,
payment or operations. We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. To ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. To choose someone to act for you such as a legal guardian or through a medical power of attorney. We will make sure such person has this authority and can act for you before we take any action. To obtain a paper copy of this notice upon request.
To exercise any of these rights, you must submit your request in writing to: Privacy Official, Prestige Health Choice LLC, 9250 NW 36th Street, 5th Floor, Doral, Florida 33178. We may charge a fee for the costs of copying, mailing or other supplies associated with your request. You may complain to Prestige if you believe your privacy rights have been violated. To file a complaint, please contact Prestige Member Services toll-free at 1-855-355-9800 or TTY 1-855-358-5856 for the hearing impaired. You may file a complaint with the secretary of the Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, SW, Washington, DC 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. You will not be penalized for filing a complaint. For further information about this notice, please contact the Prestige compliance officer: Compliance Officer (Privacy Official) Prestige Health Choice 9250 NW 36th Street, 5th Floor, Doral, FL 33178 1-866-337-2821
This information is available for free in other languages. Please contact our customer service number at 1-855-355-9800 or TTY/TDD 1-855-358-5856, 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de Servicio al Cliente al 1-855-355-9800 o TTY/TDD 1-855-358-5856, las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou an nan nimewo 1-855-355-9800 oswa 1-855-358-5856 pou moun ki pa tande byen, 24 sou 24, 7 sou 7. PRES-1522-01 M1153_1501
HEALTH CHOICE ® www.prestigehealthchoice.com
