Member Resources

Member Rights and Responsibilities

Highmark Wholecare and its network of providers do not discriminate against members based on race, sex, religion, national origin, disability, age, sexual orientation, gender identity, or any other basis prohibited by law.

As a Highmark Wholecare member, you have the following rights and responsibilities.

1. Member Rights
   
2. Member Responsibilities

Member Rights
You have the right: 

1. To ask for changes or corrections to your records. To be treated with respect, recognizing your dignity and need for privacy, by Highmark Wholecare staff and network providers.
2. To get information in a way that you can easily understand and find help when you need it.
3. To get information that you can easily understand about Highmark Wholecare, its services, and the doctors and other providers that treat you.
4. To pick the network health care providers that you want to treat you.
5. To get emergency services when you need them from any provider without Highmark Wholecare’s approval.
6. To get information that you can easily understand and talk to your providers about your treatment options, risks of treatment, and tests that may be self-administered without any interference from Highmark Wholecare.
7. To make all decisions about your health care, including the right to refuse treatment. If you cannot make treatment decisions by yourself, you have the right to have someone else help you make decisions or make decisions for you.
8. To talk with providers in confidence and to have your health care information and records kept confidential.
9. To see and get a copy of your medical records and to ask for changes or corrections to your records.
10. To ask for a second opinion.
11. To file a Grievance if you disagree with Highmark Wholecare’s decision that a service is not medically necessary for you.
12. To file a Complaint if you are unhappy about the care or treatment you have received.
13. To ask for a DHS Fair Hearing.
14. To be free from any form of restraint or seclusion used to force you to do something, to discipline you, to make it easier for the provider, or to punish you.
15. To get information about services that Highmark Wholecare or a provider does not cover because of moral or religious objections and about how to get those services.
16. To exercise your rights without it negatively affecting the way DHS, Highmark Wholecare and network providers treat you.
17. To create an advance directive. See Section 6 on page 70 of the Member Handbook for more information.
18. To make recommendations about the rights and responsibilities of Highmark Wholecare’s members.

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Member Responsibilities

Members need to work with their health care service providers. Highmark Wholecare needs your help so that you get the services and support you need. 

These are the things you should do:

1. Provide, to the extent you can, information needed by your doctors.
2. Follow instructions and guidelines given by your doctors.
3. Be involved in decisions about your health care and treatment.
4. Work with your providers to create and carry out your treatment plans.
5. Tell your doctors what you want and need.
6. Learn about Highmark Wholecare coverage, including all covered and non-covered benefits and limits.
7. Use only network doctors unless Highmark Wholecare approves an out-of-network doctor or you have Medicare.
8. Get a referral from your primary care physician (PCP) to see certain specialists.
9. Respect other patients, provider staff, and provider workers.
10. Make a good-faith effort to pay your co-payments.
11. Report fraud and abuse to the DHS Fraud and Abuse Reporting Hotline.

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