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Getting the most from my coverage: It's all part of my plan

Get the Most from Your Coverage

You deserve good healthcare. You also deserve the information you need to make the most of your coverage. SilverSummit's goals for quality are set and reviewed to make sure you get the care you need.This information is part of a Quality Program that works to improve your care and services. It explains what your coverage includes and what services are available to you.

Contact Member Services to learn more about the Quality Program.

Know Your Rights

As a Member, here are some things you should expect from your health plan:

These are some of your rights:

  • You can use all the services offered to members.
  • You should be treated with respect.
  • You can ask for a copy of your medical record.
  • Your health information will be kept private. There are rules to protect your records.

Here’s what you can do to get the most from your coverage:

  • Ask questions if you don’t understand your rights.
  • Keep your scheduled appointments.
  • Carry your Member ID Card to all visits.
  • Tell your doctor if you had care in an emergency room. 

The full list of rights and responsibilities is in your Member Handbook.

Your Privacy

We keep your race, ethnicity, language (REL), sexual orientation, and gender identity (SOGI) information private.

Here’s how we protect it:

  • Paper files are kept in locked cabinets.
  • Electronic files stay on secure systems.
  • Your information is stored in password-protected files.

We may use your REL and SOGI information to:

  • Create programs to help Members.
  • Create educational outreach materials.
  • Tell doctors about your language needs.
  • Study health care disparities among groups.

We will never use this information to set rates, decide benefits, or share it with people who are not allowed to see it.

Getting the Care You Need

Your PCP is the doctor you see for checkups and regular care. They can help you find other doctors if needed. You can also use Find-a-Provider Tool on website.

As kids grow up, they should switch from a pediatrician to an adult doctor. Teens don’t need checkups as often as younger kids, but they should see their PCP at least once a year. This helps them stay up to date on vaccines. If a teen has a condition like diabetes or asthma, they should never skip visits. Call Member Services at 1-844-366-2880  (TTY/TDD: 1-844-804-6086 Relay 711) if you need help finding an adult doctor.

You should be able to make an appointment with your PCP and get care when you need it. Sometimes, it may take longer to see specialists. Call Member Services at 1-844-366-2880  (TTY/TDD: 1-844-804-6086 Relay 711) if you can’t get an appointment soon enough.

Interpreter services are free when you talk to the health plan or doctors, and during the grievance process. This includes American Sign Language and real-time interpretation by certified medical interpreters.If you need something translated, call Member Services at 1-844-366-2880  (TTY/TDD: 1-844-804-6086 Relay 711). We can also give materials in Braille, CD, or large print.

If you need an interpreter for a medical visit, call us before your appointment. We will arrange it for you.

You should get the right medicines for your health needs. But not all drugs are covered, and some need approval first. The Preferred Drug List (PDL) is on the website. It is updated often and shows which drugs are covered. Talk to your doctor or pharmacist if you have questions.

The Utilization Management (UM) team reviews your health records and may talk to your doctor to decide if a service is covered. These decisions are not based on money. Doctors and staff are not paid to deny care. All decisions are based on:

  • If the service is medically needed.
  • If the service works well.
  • If the service is right for you.

New medicines, tests, and procedures come out every year. A team of doctors and experts decides whether new care will be covered. Your plan covers care that is medically needed. Not every new service is covered for all Members.

If a service is denied, you can appeal. You will get a letter explaining how to do this. Appeals are reviewed based on your request, condition, and benefits.

Care Management is for members who need extra help with their health. Some people have many health problems and see several doctors. Others need help setting up services their doctors ordered. A care manager can help you understand your health, work with your doctors, and get the care you need.Your Member Handbook is a great source for information about your coverage and benefits. It also lists important phone numbers.

Get More Information

Your Member Handbook is a great source for information about your coverage and benefits. It also lists important phone numbers.

 

Call: You can also contact Member Services for additional help at 1-844-366-2880. Translation services are available if you need them.

Member Services to get:

  • A paper copy of your Member Handbook, Privacy Notice or anything on your health plan website
  • Help finding a doctor and making an appointment
  • Help speaking with a care manager
  • Help with an appeal for a service that’s been denied
  • Help with a ride to your appointment

 

Your health plan website also has a lot of helpful information. Visit it to find the Member Handbook, Find-a-Provider tool, and the Preferred Drug List. You can also use it to help you manage your health.

 

Creating an online member account is free and easy. With it, you can:

  • Find or change your PCP
  • Request a new Member ID Card or print a temporary ID Card
  • View and update your personal information

You can also send a message directly to your health plan from your member account.