Akeso Care Management (ACM)
Consumer Rights & Responsibilities Policy
In their interactions with ACM, consumers have rights and responsibilities, which include:
Qualified Health Care Professionals
Utilization management activities are administered by qualified health care professionals.
Only physicians issue non-certification determinations.
Consumers have the right to receive accurate, easily understood information regarding the precertification process and its requirements.
Respect and Nondiscrimination
Consumers have the right to considerate, respectful service from case managers, intake coordinators and all other ACM employees involved in the utilization management process.
Confidentiality of Health Information
Consumers have the right to communicate with ACM case managers and other staff in confidence, and to have their individually identifiable health information remain confidential and protected.
Consumers have the right to report complaints and expect a response.
Complaints may be registered with any ACM staff member or a manager.
Complaints will be handled according to the ACM Complaints and Grievances process, which is available to consumers upon request.
Appeals, Peer to Peer Conversations and Clinical Rationale
Consumers have the right to a fair and efficient process for resolving differences with ACM for precertification determinations.
Consumers may request a copy of the clinical rationale used in reaching a non-certification determination.
Consumers, or their treating physician, may request a Peer to Peer Conversation to discuss the clinical details of a case before a determination is made, or after a non-certification determination is made.
Consumers may request an appeal (see Appeals process) when a non-certification determination has been issued.
Consumer Responsibilities Consumers have a responsibility to participate in the utilization management process, including:
A. Disclosing relevant information and clearly communicating wants and needs.
Using ACM’s complaint and appeal processes to address concerns that may arise.
Being knowledgeable about their health plan coverage including limitations, benefits, exclusions, and network providers.
Abide by administrative and operational procedures of their health plan.
Report wrongdoing and fraud to the appropriate resources or legal authorities.