Patient Rights and Responsibilities for Quest Behavioral Health Members
Quest Behavioral Health Network providers should inform members of procedures, patient rights and responsibilities during their treatment, allowing members to have a fully-informed treatment experience.
Your Quest provider should discuss and/or provide you with:
- A copy of Quest’s authorization for services upon request (if applicable)
- Member Rights and Responsibilities
- Confidentiality Policies and Procedures
- Co-pays, co-insurances, and/or deductibles
- Office policies regarding member financial responsibility
- Clinical Emergency and On-Call Procedures
- Potential Medication Risks and Side Effects (if applicable)
- Options for treatment
- Communication with Primary Care Doctors, healthcare professionals, behavioral health providers, or your health plan
PATIENT RIGHTS AND PROTECTIONS
AGAINST SURPRISE MEDICAL BILLS
When you get emergency care or are treated by and out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance, and/or deductible.
What is “balance billing”? (Sometimes this is called “surprise billing”)
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or must pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed a contract with Quest to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays, and the full amount charged for a service. This is called “balance billing”. This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
You’re protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balance billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, hospitalist, or intensivist services for behavioral health. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re NEVER required to give up your protections from balance billing. You also aren’t required to get out-of-network care. If in-network care is available, you can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
- You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to the out-of-network providers and facilities directly.
- Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact Quest Behavioral Health at 800-364-6352. The federal number for information and complaints is 800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.