Optum Idaho Behavioral Health Plan- 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.
Your Member Rights:
• A right to receive information about the organization, its services, its practitioners and providers and member rights and responsibilities.
• A right to be treated with respect and recognition of your dignity and right to privacy.
• A right to participate with practitioners in making decisions about your health care.
• A right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• A right to voice complaints or appeals about the organization or the care it provides.
• A right to make recommendations regarding the organization’s member rights and responsibilities policy.
• A 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.
• A right to get a second opinion from a provider at no cost to you. You can get a second opinion when you:
- Need more information about a treatment.
- Think the provider is not providing the right care.
• A right to choose your providers from the Optum network. This includes not being required to use the same provider for multiple services or not being denied treatment if multiple services are not obtained from the same provider or agency.
• A 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 specify which people you do or do not want to make choices for you.
• A 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 can view those records based on those laws and rules. You also have the right to request your records be amended or corrected according to federal and Idaho laws and rules.
• A right to ask for and get information about Optum. This includes Optum services and network providers, and how to access both
• A right to not be restrained or secluded as described in federal and state rules on the use of constrants 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 or you may have your provider, lawyer or a person you trust request an appeal on your behalf with your written consent. 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 by clicking here 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. 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
Fax: 1-855-272-7053 | Phone: 1-855-202-0973
Your appeal request 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. 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 a.m. to 6 p.m. MT to file a complaint. You also can send your complaint through Fax at 1-877-220-7330, email your complaint to firstname.lastname@example.org 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?
We will send a letter within five business days after we receive your complaint. This is to let you know that we received it. We will send 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. 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.
• A responsibility to supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
• A responsibility to follow plans and instructions for care that you have agreed to with your practitioners.
• A responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
• A responsibility to let your providers know if your treatment and recovery plans need to be updated to meet your changing needs.
• A responsibility to keep, change or cancel appointments instead of missing the appointment without telling the provider.
Nondiscrimination Notice and Access to Communication Services
Optum does not discriminate on the basis of 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 the toll-free number (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.
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
Language Assistance Services and Alternate Formats
Alternate formats:This information is available in other formats like large print. To ask for another format, please call 1-855-202-0973 TTY 711.
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Your voice matters! Member input and guidance is vital to helping us transform the mental health system.
Please email email@example.com with your feedback.