Provider Summary Guide

12 tips to make the most of your health plan

1. Know your rights and learn about the health plan’s quality program. To review your rights and responsibilities as a health plan member and to learn about the health plan’s quality program and goals, please visit your health plan’s website. If you would like a written copy of our quality program or a copy of your rights and responsibilities, please call Member Services. You may also find a written copy of the Rights and Responsibilities document on the Quality section of your health plan’s website.

2. Read your benefit information. Your benefit documents and Summary of Benefits and Coverage are a good source of information. The documents help you understand:

  • The benefits and services you have
  • The benefits and services you don’t have (exclusions)
  • How to get your prescription drugs and what drugs are covered
  • Your share of cost or ways you can pay for health care
  • What to do if and when you need to submit a claim
  • How to find out about participating providers
  • What to do if you need care when you are out of town
  • How and when to get routine, after-hours, specialty and emergency care
  • How to voice a complaint or appeal a coverage decision
  • How to get care from specialists, hospitals and mental health providers

If you need another copy of this information, please call the Member Services phone number on the back of your health plan ID card. You may also find a written copy of general benefit information on your health plan’s website.

3. Know what to do if you have an issue. We’ll definitely want to know if you have an issue. We strive to meet your needs. If you are unhappy with services or care, or with the health plan in general, please call Member Services or write a letter to Health Plan of Nevada or Sierra Health and Life. Either way, we will respond to your issue.

4. Know how to get information at your fingertips. Did you know your health plan has online tools to help you? You can search our electronic provider directory, search for covered drugs in the preferred drug list and get personal benefit information in the online member center. The online member center can help you day or night and even on holidays. Take advantage of these convenient service features to:

  • Change your address
  • Request replacement health plan ID cards
  • Verify your coverage for pharmacy, dental or vision services
  • Review the status of a claim
  • Find out who is on record as your primary care physician
  • Check the status of a prior authorization request
  • Find out how much has been applied toward your calendar-year deductible, if applicable

5. Know that we research new medical technology. For safety reasons, we formally evaluate new and emerging medical discoveries before including them in our member benefit package. Conducted by a highly-skilled technical staff that includes physicians, our review process evaluates new technology against medical standards and clinical research to assess the effectiveness and safety of new medical procedures, drugs and devices. We also research new applications of existing technologies. If you, your providers or other interested parties would like to submit a request for the review of new medical technology, please contact Member Services.

6. Ask for help if you speak another language. If you need help with communication, such as the services of a language interpreter, please call Member Services.

7. Know that the health plan does not offer incentives for prior authorization denials. Health Plan of Nevada and Sierra Health and Life prohibit the compensation of physicians, other health care professionals or staff to be based upon or used as an incentive for the denial of benefits. All decisions regarding your benefits are given special consideration based on your medical needs and the appropriateness of the care and service. Health Plan of Nevada and Sierra Health and Life employees who perform utilization review duties do not receive any incentives, financial or otherwise, to encourage denial of benefits. That is, we provide no incentive for anyone on our team to restrict benefits for our members. For more information, please call Member Services.

8. Learn about internal and external review for denial of benefits. If a benefit is denied, we provide internal review to help ensure member satisfaction in the medical decision-making process. Additionally, external independent review is provided by a panel of impartial medical professionals for eligible denials that have already undergone internal review. Expedited appeals are available when decisions are needed quickly. For additional information, please refer to your plan documents or call Member Services.

9. Know that we have special programs available for members. Are you looking for extra help? You may be eligible for additional benefits from one of the programs below.

  • Disease Management: If you have diabetes or asthma, you may be eligible to receive educational materials and calls from a registered nurse or health coach. For more information, call the Disease Management Program toll-free at 1-877-692-2059, TTY 711, on weekdays between 8 a.m. and 5 p.m. PST.
  • Complex Case Management: This program provides additional assistance for members with extra special needs. For more information, contact Member Services.

10. Know that we evaluate the care you receive. If you are admitted to a non-contracted facility or receive care or services outside of the Health Plan of Nevada or Sierra Health and Life service area, we may perform a retrospective review (after care was received) to evaluate the appropriateness of the medical care, services, treatments and procedures you received. As part of this process, we will review your medical records, admitting diagnosis and presenting symptoms. Keep in mind, access to non-emergency care outside of the contracted provider network or service area may not be covered and may incur additional expense for you or your family.

11. We want to hear from you. You may get a survey in the mail about your health plan. We need your help so we can monitor our plan and make improvements for our members. Surveys you may get include the:

  • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • Health Outcomes Survey (HOS) for Medicare members
  • Patient Satisfaction Survey
  • Disease Management Program Satisfaction Survey
  • Complex Case Management Program Satisfaction Survey
  • Telephone Advice Nurse Program Satisfaction Survey

Members are randomly selected for these surveys. If you get one, please fill it out. Your input is valuable to us.

12. Make an investment in your future. It’s one that pays solid dividends, too. Keeping up with recommended health screenings may help your primary care physician take care of the little things — before they become more serious. At your next appointment, please talk to your primary care physician about screenings and recommendations. Depending on your medical history, your provider may have additional medical advice. You can find the preventive guidelines on your plan’s website.