Rights & Responsibilities

Rights & Responsibilities

As a member of CHRISTUS Health Plan, you have certain rights and responsibilities. It is important that you fully understand them, so this section explains your rights and responsibilities for each plan.

As a member of the plan, you have the right to:

  • Available and accessible services for Medically Necessary and Covered Services, including 24 hours per day, 7 days per week for Urgent or Emergency Services, and for other Health Care Services as defined by this Policy or Summary of Benefits and Coverage.
  • Be treated in a prompt, courteous and responsible manner that respects your dignity and privacy.
  • Affordable health care including information regarding your out-of-pocket expenses; limitations; the right to seek care from a Non-Participating Provider; and an explanation of your financial responsibility when services are provided by a Non-Participating Provider or without Prior Authorization.
  • Choose a Primary Care Provider within the limits of the Covered Services, the Plan’s network and, as provided by the Policy, including the right to refuse care of specific Health Care Professionals.
  • Be promptly notified of termination or changes in benefits, services or the Provider Network.
  • Confidential handling of all communications, including medical and financial information maintained by the Plan. CHRISTUS Health Plan and our Providers will maintain privacy of your medical and financial records in accordance with existing law.
  • A complete explanation of why a benefit is denied, the opportunity to appeal the denial decision to our internal review and the right to request help from the Superintendent.
  • Know, upon request, of any financial arrangements or provisions between the Plan and our Participating Providers, which may restrict referrals or treatment options or limit the services offered to you.
  • Qualified Health Care Professionals for treatment and services that are Covered Benefits near where you live or work within the Plan’s Service Area.

For a full list of Member Rights please refer to the New Mexico Health Insurance Exchange Evidence of Coverage.

As a Member of the Plan, you have the responsibility to:

  • Provide honest and complete information to those providing care.
  • Review and fully understand the information you receive about your Plan.
  • Know the proper use of the services covered by the Plan.
  • Present your Plan ID card before you receive care.
  • Consult your Physician before receiving medical care unless your condition is life threatening.
  • Promptly notify your Provider if you will be delayed or unable to keep an appointment.
  • Pay all charges or Copay/Coinsurance amounts, including those for missed appointments. This also applies to Deductibles and any charges for Non-Covered Benefits and Services.
  • Express your opinions, complaints or concerns in a constructive way to CHRISTUS Health Plan Member Services or to your Provider.
  • Inform the Plan of any changes in family size, address, phone number or membership status within 30 calendar days of the change.
  • Make Premium payments on time.
  • Notify the Plan of other insurance coverage.
  • Follow our Grievance and Appeal process when displeased with the Plan or a Provider’s actions or decisions.
  • Understand your health problems and participate in developing treatment goals that you agree to with your Providers.
  • Follow plans and instructions for care that you have agreed to with your Provider.

All Members are responsible for understanding how the Plan works. Please refer to the Forms & Documents section for more information on your plan.

MM161 & MM162
Last Updated: 2/23/17