Managed Care Disclosure (for GHI HMO Members)
The following is information about GHI HMO that we must give to all HMO members or prospective GHI HMO members who request the information. Additional details about the following items are in your Member Handbook or Certificate of Insurance:
About GHI HMO
The names, business addresses and titles of officers, directors, owners and controlling persons of GHI.
How to get a copy of:
- The most recent annual financial statements.
- GHI HMO's most recent direct payment contracts.
Information about:
- GHI's Consumer complaint program.
- How GHI HMO protects our members medical records and other member information.
- GHI HMO's quality assurance procedures.
- GHI HMO's Utilization Review program works including Utilization Review policies and procedures as well as clinical review criteria. This includes information about certain diseases and conditions that are covered.
About GHI HMO's Benefits
How to get a copy of:
- The preferred prescription drug list, if you have a GHI HMO prescription drug benefit.
How to get a list of:
- All participating providers (including facilities), along with their specialty, address, and telephone number including whether they are board certified and what hospitals they are affiliated with.
Information about:
- The minimum qualifications for providers to be in GHI HMO's network.
- What services need prior authorization.
- How to get emergency services, 24 hours a day.
- How to select primary and specialty providers and get services. This includes information about how to get a referral to a non-network provider in certain cases.
- How a member may get a referral to a specialist provider, and how that referral can become a standing referral.
- How a member with a life-threatening condition or a degenerative and disabling condition or disease which requires specialized medical care, can request a specialist Primary Care Physician or access to a specialty care center.
- How GHI pays providers.
How GHI HMO decides which experimental/investigational treatments, drugs, and devices procedure can are covered.
A description of all benefits including benefit maximums, coverage exclusions, and the definition of medical necessity.
GHI HMO and Members
Information about:
- The member's responsibility for payment of premiums, coinsurance, copayments, and deductibles and definitions of these words.
- The member's responsibility for payment of services by non-network providers or for noncovered services.
- GHI HMO's process and for filing a grievance?.
- How members can participate in the development of GHI HMO's policies.
- How non-English speaking members are served.
- How members can contact GHI HMO.
If you have questions about the Managed Care Act Disclosure Provision, would like copies of information about GHI HMO, or for any other questions, please call GHI HMO Customer Service Department toll free at 877-2GHIHMO (877-244-4466).
