RIGHTS & RESPONSIBILITIES
Every member has rights and responsibilities for care under Optum Idaho.
Read below so you are aware of the choices you have when seeking care.
Member Rights include:
- You have the right to be treated fairly, with dignity and with respect for your right to privacy.
- You have the right to receive all health care services in a caring, non-judgmental way.
- If you have a communication disability you have the right to receive information in a style that meets your needs.
- You have the right to get health care services in a way that respects your culture. This includes getting you an interpreter if you do not speak English.
- You have the right to take part in all health care decisions. This includes treatment and recovery planning. You also have the right to refuse treatment.
- You have the right to understand any treatment you agree to receive. This is called informed consent.
- You have the right to choose someone to help with care choices
- You have the right to get a second opinion from a provider at no cost. You can get a second opinion when you:
- Need more information about a treatment.
- Think the provider is not providing the right care.
- You have the right to make a complaint about the care you are receiving. This is a way to take charge of your recovery. Complaints can be made about Optum, a provider contracted with the Optum network, or anything else about your treatment experience.
- You have the right to choose your providers from the Optum network.
- You have the right to have a psychiatric advance directive (PAD). A PAD is a legal document you can use to manage your mental health treatment and wellness if you cannot make or communicate decisions about your treatment. A PAD can say which people you do or do not want to make choices for you.
- You have the right to see your own behavioral health treatment records. This is based on federal and Idaho laws and rules. You have the right to restrict who sees those records based on those laws and rules.
- You have the right to ask for and get information about Optum. This includes its services, its network providers, and how to access them.
- You have the right not to be bothered by either side if problems come up between Optum and its network providers.
- You have the right to not be restrained or secluded based on federal or state rules on the use of restraints and seclusion.
What is an appeal?
You may file an appeal when you are not happy with an Optum Idaho adverse benefit determination. For example, you can file an appeal when a covered service is denied, delayed, limited or stopped.
Who can file an appeal?
You can file an appeal. A provider or someone acting for you can also file an appeal for you, with your written permission. You will not be penalized for filing an appeal.
How do I file an appeal?
If you would like to file an appeal, please complete the Appeal Request Form below and submit to Optum using the options listed below or on the form.
You can start an appeal over the phone, in writing or in person. Appeals filed over the phone must be followed up in writing, unless it is an urgent request and meets the urgent appeal criteria. An urgent request is when you, Optum Idaho or your provider thinks Optum Idaho needs to make a quick decision based on your health.
You must file your non-urgent appeal within 60 calendar days of the denial letter’s date. If you wish to continue receiving services that were terminated, suspended or reduced, you must file an appeal within 10 calendar days of the denial letter. You can give Optum Idaho evidence to support your appeal in person or in writing. You can call Optum Idaho Member Services at 1-855-202-0973 Monday through Friday, 8 a.m. to 5 p.m., Mountain Standard Time, to get help.
322 E. Front Street, Suite 400
Boise, ID 83702
The appeal request form is included with Optum denial letters. The completed Appeal Request Form must include:
1. Member information:
- Medicaid Identification Number
- Date of Birth
2. Your contact information
3. Any extra information that you think should be considered
4. An explanation of why you disagree with Optum’s decision; and
5. If applicable – the name and signature of any individual that is filing an appeal on the Member’s behalf. Members’ signatures are also required when authorizing a representative to file an appeal on their behalf.
How long will it take to process my non-urgent appeal?
Within five days of receiving your appeal, Optum Idaho will send you written confirmation that we have received your appeal.
We will tell you and your provider the outcome of the appeal within 30 calendar days. We will send you a letter telling you the outcome. If we need more time to review your appeal, we can ask Idaho Department of Health and Welfare for 14 more calendar days. If the Department agrees, we will let you know in writing.
How long will it take to process my request for urgent review of my appeal?
We will tell you and your provider the outcome of the appeal within 72 hours. We also will send you a letter telling you and your provider the outcome. Optum has the right to deny a request for an urgent review of an appeal if the appeal is determined to not be of urgent status. If Optum Idaho denies the request for an urgent review of an appeal, the appeal will go through the non-urgent appeal process, and Optum Idaho will call the requesting party to alert them the urgent review was denied. We will also follow up in writing.
What if I am not satisfied with the appeal decision?
If you disagree with Optum’s appeal decision, you may ask for a State Fair Hearing with the Idaho Department of Health and Welfare. This can only be done after you have appealed with Optum first. You have 120 days from the date of Optum’s appeal resolution to file a Fair Hearing.
Will I still get my benefits during an appeal review or Fair Hearing?
You have the right to continue any service you are getting pending the decision if:
- You request an appeal review within 10 days of receiving Optum Idaho’s Adverse Benefit Determination or ask for a Fair Hearing within 10 days of Optum Idaho’s appeal resolution.
- The appeal review involves a service you were already approved to receive.
- The services were ordered by an approved provider.
- The time period of the service has not run out.
If you get services during the appeal review, but the decision is not in your favor, you may have to pay for those services.
What is a complaint?
A complaint is an expression of dissatisfaction about Optum Idaho or a provider.
What should I do if I have a complaint?
If you have a complaint about Optum Idaho or a provider, call Customer Support Services. Any staff member can help start the complaint process. All Optum Idaho employees can accept complaints and document the specific details within Optum’s complaint system. If you prefer, a Peer or Family Support Specialist can help you with the filing.
Call Optum Idaho Member Services at 1-855-202-0973 weekdays from 8:00 a.m. to 5:00 pm, Mountain Standard Time, to file a complaint. You also can send your complaint through Fax at 1-855-272-7053, or mail to:
322 E. Front Street, Suite 400
Boise, ID 83702
Who can file a complaint?
You may file a complaint or an authorized representative may also file the complaint on your behalf. You will not be penalized for filing a complaint.
How long will it take to process my complaint?
You will receive a letter within five working days after we receive your complaint. This is to let you know that we received it. You will get a letter with a resolution within 10 business days after we receive your complaint.
What does Optum Idaho do when we find out about possible quality of care complaints? A member, an authorized representative or a provider may file a complaint about a possible quality of care issue. A quality of care issue means the quality of services provided to a member may be poor or unsatisfactory. Quality of care complaints should be filed the same way as other complaints. Our Quality Department will decide if the complaint qualifies as a quality of care issue.
Optum Idaho’s Quality Department will investigate if the complaint qualifies as a quality of care issue. Any actions taken by Optum Idaho to address the complaint are confidential. This means that Optum Idaho will advise the person filing that the matter has been referred as a quality of care complaint. We will not advise the person of the investigation’s final outcome.
Optum asks that every member is aware of the following responsibilities:
You are responsible for providing Optum and its providers with information needed to provide quality care.
- You are responsible for understanding your health problems to the best of your ability. You are responsible for participating in treatment and recovery goals both you and your care providers agree on.
- You are responsible for following these treatment and recovery plans to the best of your ability. You must let providers know if changes are needed.
- You are responsible for keeping, changing or cancelling appointments instead of not showing up.
Optum Idaho does not exclude people or treat them unfairly because of their sex, age, race, color, national origin, or disability.
Free services are available to help you communicate with us. Such as, letters in other languages, or in other formats like large print. Or, you can ask for an interpreter. To ask for help, please call (855) 202-0973. TTY 711.
If you think you weren’t treated fairly because of your sex, age, race, color, national origin, or disability, you can send a complaint to:
Optum Civil Rights Coordinator
11000 Optum Circle
Eden Prairie, MN 55344
Phone: 888-445-8745, TTY 711
If you need help with your complaint, please call the toll-free number (855) 202-0973, TTY 711. You must send the complaint within 60 days of when you found out about the issue.
You can also file a complaint with the U.S. Dept. of Health and Human services.
Civil Rights Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
This information is available in othe formats like large print. To ask for another format, please call 1-855-202-0973 TTY 711
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