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Web Information Privacy Policy | Member Privacy Policy | Protégé Su Privicidad

Member Rights & Responsibilities |   Derechos y responsabilidades de los asociados  Member Grievance & Appeals  |  Cómo presentar una queja (Reclamo)

Preferred Care Web Information Privacy Policy
Preferred Care has an ongoing commitment to protecting online information according to applicable laws, regulations, and accreditation standards and practices. Preferred Care is committed to protecting personal information submitted to our web site, just as we are committed to protecting personal information that is provided to us over the phone, in person, or through the mail.

We have established this privacy policy to ensure the confidence of visitors and members; and as a demonstration of our commitment to fair information practices and protection of privacy. This privacy policy may be updated from time to time in accordance with the notification requirements set forth below.

Privacy Practice

1. Collection of personally identifiable information
Preferred Care may collect e-mail addresses of visitors that communicate with Preferred Care via e-mail; Preferred Care may collect information provided in registration forms, surveys, and other online avenues.

2. Use of information collected by Preferred Care
Personally identifiable information you provide to Preferred Care through this Web site will only be used for the express purpose of your disclosure to us, unless otherwise described in this policy or as is required or permitted by law. Such information may also be shared with our business associates in connection with services and products that you request, or to provide you with health information that we believe will be of interest to you. Our business associates include, but may not be limited to, all of our affiliated companies as well as other selected businesses with which we have a business relationship and that we feel adhere to our principles of quality products and services. In addition, we may be required to share information in accordance with applicable law.

3. Collection and use of non-personally identifiable information
Non-personally identifiable information collected when visitors use this site may be used for internal review purposes, including measuring and monitoring use of our site, diagnosing problems with our server, and/or administration of our site. When visitors access our site, data is collected and used to track areas of this web site that are most frequently visited to help us to continuously improve this site.

4. General non-confidentiality of information on the Internet
Preferred Care has implemented security features to help prevent unauthorized release of or access to personal information that has been received through our Web site. For example, messages sent to Preferred Care through forms and online applications are SSL encrypted/secured. However, messages sent via Outlook Express or other e-mail providers may not be secure. Although we make efforts to secure information transmitted to us, the confidentiality of any communication, information or other material transmitted to or from Preferred Care through this site or through e-mail cannot be guaranteed. Therefore, Preferred Care is not responsible for the security or confidentiality of information being transmitted via e-mail Internet or other global computer networks.

5. Preferred Care's right to change our privacy policy
Preferred Care may, from time to time, update its privacy policy. If updates or changes are made to our policy, we will post those changes in a timely manner so that you will be aware of changes that may affect you. Please refer back to this policy periodically to review changes and/or updates.

Preferred Care adheres to all HIPAA regulations and is committed to keeping your personal information confidential. Our corporate privacy policy is described below.

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Preferred Care Member Privacy Policy
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

As a Preferred Care member, you agree to let Preferred Care share information about you for medical treatment, payment or health care operations. Protecting the privacy of information about your medical conditions and health is a responsibility we take very seriously. We understand that medical information about you and your health is personal, and it is important to you that we keep it confidential. Preferred Care is committed to the rules and standards we developed to protect the confidential nature of information about your health.

By law, Preferred Care needs to tell you about our rules and how we collect, use, share and protect your personal information. This notice is part of a comprehensive privacy program that Preferred Care has put into place in order to comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the requirements of New York law regarding health information confidentiality and with other applicable New York State regulations.

What information is protected by the law? The rules define Protected Health Information, as:

• health information that may identify you, and
• health information that is created or kept by a health care provider or health plan.

Health Information: includes information that relates to all of your health services, arranging for your health care or payments for your health services.

Preferred Care needs to know these things about you:

• Name
• Address and phone number
• Date of birth
• Your Preferred Care ID number
• Where you work or used to work
• Social Security number.

Preferred Care also collects other information about you, like:

• Why the doctor sees you
• What the doctor does for you
• Preferred Care services you use.

Preferred Care finds this out from:

• Bills that Preferred Care gets from your doctor
• Letters or calls from your doctor Your medical records
• Other insurers that may pay for some of your care
• Surveys that have your name or ID number on them
• The local, state or federal government if they pay for any part of your coverage.

Here are the ways that Preferred Care is allowed by law to use your information.

Preferred Care uses this information:

• To help you get medical care from your doctor, your hospital or others
• To pay claims for your health care services
• To find and mail helpful tips to people who have a health problem, like asthma
• To mail reminders about visits to your doctors
• To mail information on care choices you have and health services that you might want to get
• To conduct its own health care operations, such as customer service, resolving grievances, underwriting insurance and conducting business planning.

The following categories, defined by law as "Routine", describe in more detail the different ways that Preferred Care may use or share information about your health without your written permission.

Treatment: Preferred Care does not provide treatment and does not use your health information for this purpose. Your health information may be used or shared with a physician or other health care provider in order for them to provide you with treatment.

Payment: This describes the activities done by Preferred Care to collect premium payments, to determine benefit coverage, or to process payments to your Health Care Provider for the health care services he/she provided to you. These activities include:

• Billing, claims management and collections activities to pay claims from physicians, hospitals and other providers for services delivered to you that are covered by your health plan
• Determining your eligibility for benefits
• Coordinating payment for services with other insurance coverage
• Determining medical need for services
• Reviewing health services
• Obtaining premiums
• Issuing explanations of benefits (EOB).

Health Care Operations: These are the activities performed as a part of running the business functions of a Health Plan. This includes activities such as:

• Customer service and resolving grievances
• Arranging for and measuring the quality of care you are given
• Coordinating for your care and management of your health situation or disease
• Evaluating our health care providers for proper certifications and evaluating their performance
• Business planning for Preferred Care
• Work Preferred Care must do to comply with applicable laws and regulations
• Preferred Care's financial reporting requirements, such as working with auditors
• Underwriting insurance
• Conducting medical review, legal services, auditing and fraud and abuse detection and compliance programs

Sometimes Preferred Care needs to work with other companies to help you and perform some functions on our behalf. These kinds of companies are called "Business Associates" of Preferred Care and must agree in writing to protect your privacy and follow the same rules we do. Examples of these companies are:

• People who print and mail your newsletter
• Auditors
• Some New York State and Federal agencies
• Other insurance companies that may pay for part of your care
• Brokers that assist in sale of benefit plans
• Doctor groups
• Companies that may help coordinate your care and manage your health situation or disease

There are other reasons Preferred Care would be allowed to share your information without your permission. These reasons, defined by law as "Non-Routine", may involve a legal process. For example, a court order or legal demand may require that Preferred Care share your information. Reasons contained in the law, include:

• Public Health Activities, where a health authority is trying to control or prevent disease, injury or disability
• Victims of Abuse, if Preferred Care is required by law to report such abuse to a government agency
• Health Oversight, where Preferred Care must disclose your information to a health oversight agency
• Law Enforcement, such as to the police or other law enforcement agency
• Coroner or medical examiner for the purpose of identifying someone whom has died
• Organ donations, if you are an organ donor
• Research purposes, if Preferred Care participates in research activities
• Serious threat to health or safety, where Preferred Care is acting to help stop or avoid a threat to public safety
• Specialized government functions, such as to Veterans Affairs, other military or other agencies
• Workers Compensation

If You Receive Health Coverage through Your Employer: Information about your enrollment in Preferred Care and/or health information from which key data that identifies you has been removed may be shared with your employer/group health plan in order to permit them to perform plan administration functions. Your employer's group health plan may also, in certain cases, be allowed access to your health information - please see your employer's plan documents for an explanation of these limited uses and disclosures.

Telling You About Health-Related Services: Your health information may be used to send you appointment reminders or to communicate with you to encourage you to purchase or use a health-related product or service (or payment for such product or service), that is provided by, or included in, a Preferred Care health plan.

This includes letting you know about:

• People who care for you (doctors, nurses and others) who work with Preferred Care
• Changes to your health plan, including replacing or enhancing your coverage
• Health-related products or services available only to health plan members. These products or services must be related to: providing your care, arranging for and measuring the quality of care you are given, coordinating for your care and management of your health situation or disease, or treatment choices.

The following categories describe the different ways that Preferred Care may use or share information about your health only with your permission.

Authorization: Preferred Care can accept an Authorization to Disclose Information from you, if you would like us to share your health information with someone other than you for a reason we have not stated above. The law has mandated that an Authorization to Disclose Information (ADI) form must include 9 standard elements. You can designate on the form how long you want Preferred Care to be able to share your information with that individual, for up to a 2 year period. A copy of this form, which is attached, can be filled out by you and sent to Preferred Care's Member Services Department.

This form is also available by calling our Member Services Department or click here to download. You must complete this form and send it to Preferred Care's Member Services department. You can cancel this Authorization at any time as described in the "Your Written Authorization is Required" section on page 6.

To Your Family and Friends: Your medical information may be disclosed to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. Your name, location and general condition or death may be used or disclosed to notify or assist in the notification of (including identifying or locating) a person involved in your care.

Preferred Care will provide you with an opportunity to object to such uses or disclosures, unless, based on professional judgment, it may reasonably infer from the circumstances that you do not object to such uses and disclosures.

If you are not present, or in the event of your incapacity or an emergency, Preferred Care will use our professional judgment in deciding whether disclosing your medical information would be in your best interest.

Your Rights Regarding Information About Your Health
You have the following rights regarding the health information we maintain about you:

Right to Inspect and Copy Your PHI: You have a right to inspect and obtain a copy of information about your health that we maintain. Usually this includes medical and billing records. Under Federal law, this right does not include:

1. Psychotherapy notes
2. Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding
3. Information obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information
4. Requests not made by you or your authorized representative.

We may deny your request to inspect and copy your health information in certain limited circumstances, such as where disclosure could reasonably endanger the life or physical safety of you or another person. If you are denied access to information about your health, you may request that the denial be reviewed.

Right to Request Restrictions: You have a right to request a restriction on the information about your health that we use or share for treatment, payment or health care operations. You also have the right to request a limit on the information we disclose about your health to someone who is involved in your care or the payment for your care, like a family member.

You can make this request by telling us in writing, using the Request for Restriction on the Use or Disclosure of Information form . You can get a copy of this form by calling Preferred Care's Member Services department or via our web site www.preferredcare.org.

Preferred Care is not required to agree to your request for a restriction.

Right to Amend Your PHI: If you believe the information we have about your health is incorrect or incomplete, you may ask us to amend the information. You must provide a reason that supports your request. You have the right to request an amendment for as long as the information is kept by or for us.

Preferred Care may deny your request for an amendment if it is not in writing or does not include a reason to support the request. Also, we may deny your request if you ask us to amend information that:

• Was not created by Preferred Care, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the health information kept by or for us;
• Is not part of the information about your health that you would be permitted to inspect and copy;
• Is accurate and complete.

Right to Request an Accounting: You have the right to receive an accounting of certain disclosures of information about your health information that Preferred Care made, if any. This right applies to disclosures for purposes other than treatment, payment, health care operations, for those disclosures authorized by you, or as otherwise permitted or required by law. You have a right to receive specific information about these disclosures that occurred for a six year period before the date you make the request, but only back to April 14, 2003 .

The accounting Preferred Care sends you will identify to whom the disclosure was made, the date of disclosure, and provide a brief description of information disclosed and the purpose of the disclosure. If you request an accounting more than once in a 12-month period, Preferred Care may charge you a reasonable administration fee for the additional requests. The right to receive this information is subject to certain exceptions, restrictions and limitations.

Right to Request Confidential Communications: If you could be endangered by the normal ways we share information with you, you have the right to request that we communicate with you about your health information by a different means or at a different location. Preferred Care will ask you the reason for your request, and it will accommodate all reasonable requests.

Right to a Copy of Preferred Care's Notice of Privacy Practices: You have the right to obtain a copy of this notice at any time.

Your Written Authorization Is Required: Other uses and disclosures of your health information that are not described above will only be made with your written authorization. You may give Preferred Care written authorization to use or to disclose your health information to anyone for any purpose.

You may revoke this authorization at any time. Gold members, please call Gold Member Services at (585) 327-2480 or (800) 665-7924. Other plan members, please call (585) 325-3113 or (800) 950-3224. TTY users call (585) 325-2629, or (800) 252-2452. You may also cancel this authorization by writing to Member Services, Preferred Care, 220 Alexander St. , Rochester, NY 14607. Please note that a cancellation by telephone must be confirmed in writing. However, your revocation will not affect any use or disclosure that you permitted, and that was made, prior to your revocation.

Your Privacy Rights:
You may exercise your privacy rights at any time by submitting your request in writing to:

ATTN: Privacy Officer
Preferred Care
220 Alexander St.
Rochester, NY 14607

Preferred Care's Duties Regarding Information About Your Health:
We are required by law to:

• Maintain the privacy of information about your health
• Provide you with this notice of our legal duties and health information privacy rules
• Abide by the terms of this notice.

Changes to This Notice:
We reserve the right to change the terms of this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. If we make a material change to the terms of this notice, we will mail a revised notice to you.

For More Information and to File A Complaint:
If you think your privacy rights have been violated, you can complain to Preferred Care. Complaints should be sent to: ATTN: Privacy Officer, Preferred Care, 220 Alexander St., Rochester , NY 14607 . You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. Complaints filed directly with the Secretary must: (1) be in writing; (2) contain the name of the entity against which the complaint is lodged; (3) describe the relevant problems; and (4) be filed within 180 days of the time you became or should have become aware of the problem. We will provide you with this address upon request. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. We support your right to the privacy of your medical information.

• If you view this notice on the Preferred Care Web site or receive it by e-mail, you are also entitled to receive it in written form
• You may request more detailed information about your rights and privacy protections or learn how to exercise those individual rights as described in this notice
• If you want a full copy of our privacy rules, please call Member Services at (585) 325-3113 or (800) 950-3224
• TTY users may call (585) 325-2629 or (800) 252-2452.
• Or, you can write to our Privacy Officer at Preferred Care, or come to our offices at 220 Alexander St., Rochester, NY 14607.

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Preferred Care Protege Su Privacidad

Este aviso le explica cómo su información médica puede ser usada por Preferred Care, cómo podemos divulgarla y cómo puede ver qué tipo de información es. Haga el favor de revisar esta información cuidadosamente. 

Como miembro de Preferred Care, usted está de acuerdo con que nosotros compartamos su información para el tratamiento, pago u operaciones que tengan que ver con el cuidado de la salud.  Nosotros no compartimos su información personal por ninguna otra razón sin su consentimiento, excepto lo que sea permitido por la ley.

Según la ley, le debemos informar sobre nuestras reglas y cómo recolectamos, usamos y protegemos su información personal.

Necesitamos saber lo siguiente sobre usted:

• Nombre
• Dirección y número de teléfono
• Fecha de nacimiento
• Su número de identificación (ID) de Preferred Care
• Lugar de trabajo o donde solía trabajar
• Número de Seguro Social

También recolectamos información sobre usted:

• El por qué el doctor lo atiende
• Los servicios que el doctor le da
• Los servicios de Preferred Care que usa

Recolectamos esta información de:

• Las facturas que recibimos de su doctor
• Las cartas o llamadas de su doctor
• Su historial médico
• Otros aseguradores que quizás paguen por alguno de los cuidados que recibe
• Encuestas con su nombre y número de identificación
• El gobierno local, estatal o federal en caso de que paguen por cualquier porción de su cobertura

Utilizamos esta información para:

• Ayudarle a recibir cuidado médico por su doctor, hospital u otro lugar/proveedor
• Pagar las facturas
• Encontrar y enviar consejos de ayuda a las personas que tienen un problema de salud, como puede ser el asma
• Enviar avisos para recordarle sobre las visitas a sus doctores
• Enviar información sobre las opciones de cuidado de salud que tiene y los servicios de salud que pudieran interesarle

Toda esta información ayuda a "identificarlo". Para su protección, tenemos reglas para el uso y distribución de esta información.

A veces necesitamos trabajar con otras compañías/grupos para ayudarle. Este tipo de compañías debe presentar su acuerdo por escrito para así proteger su privacidad y cumplir con las reglas:

• Las personas que imprimen y envían los boletines de noticias
• Auditores
• Algunos grupos estatales y federales
• Otras compañías de seguros que quizás paguen una parte de su cuidado médico
• Grupos de doctores

Al menos que tengamos su aprobación por escrito, no podemos compartir información sobre usted con nadie - ni siquiera con su familia - excepto lo que sea permitido por la ley.

Tal vez quiera permitir que un miembro de la familia, amigo, o alguien más hable con nosotros sobre su cuidado de salud y que vea el historial. En tal caso, debería rellenar una forma llamada "Autorización para divulgar información" ("Authorization to Disclose Information").  Puede obtener esta forma llamando a Servicios para Miembros (Member Services) a los números que aparecen al final de esta historia. También puede llamarnos para cancelar esta forma.

Divulgación de la información sobre usted

• En cualquier momento, puede pedirnos ver una copia confidencial de la información que tenemos sobre usted y su salud y nosotros se lo permitiremos. Este tipo de peticiones debe hacerse por escrito
• Puede pedirnos (por escrito) una copia de esta información, y nosotros se la daremos. Puede que exista un cargo por la obtención de esta copia
• Tiene derecho a pedirnos que añadamos algo a la información sobre su salud y a que hagamos correcciones
• Puede pedirnos que le digamos las veces que hemos compartido información sobre usted por cualquier razón que no sea mencionada aquí
• Puede elegir si quiere que divulguemos alguna información sobre usted
• Puede pedirnos que no compartamos la información que Preferred Care necesita compartir para que se lleve a cabo un tratamiento médico, el procesamiento de un pago o el manejo de nuestro negocio.  Preferred Care no tiene por qué aceptar su petición
• Puede pedir otras clases de restricciones sobre el tipo de información que divulgamos sobre usted y puede que nosotros estemos de acuerdo. También podemos finalizar esta restricción
• Si usted muestra por escrito que está de acuerdo o si pide que finalice la restricción
• Si usted está de acuerdo y nos lo dice, y existe un testigo que presencia el acuerdo
• O, si le notificamos por escrito
• Si el envío de información confidencial a su casa le pudiera poner a usted en peligro, puede pedirnos que se la mandemos a otra dirección o que se la demos de otra manera que no sea por correo postal.

¿Cuándo debemos divulgar información sobre usted?
Si nos lo piden como parte de un proceso legal: por ejemplo, en caso de una autorización o citación legal u otra petición hecha por el tribunal o cualquier otra entidad judicial o grupo administrativo que tenga la autoridad legal para hacerlo.

¿Cómo protegemos su información?

• Cumplimos con reglas estrictas para proteger su privacidad
• Únicamente se le permite ver su información a nuestros empleados que lo necesitan
• Nuestros empleados están entrenados en asuntos de privacidad
• Nuestros empleados acuerdan, por escrito, proteger su privacidad.  Si alguien rompe este acuerdo, él/ella puede ser sancionado/a
• Un comité especial revisa para asegurarse de que cumplimos con las reglas
• Tenemos un Oficial de Seguridad de Información que está encargado de la seguridad de su información
• Nuestro sistema de computadoras tiene varias maneras diferentes de proteger su información.

Preferred Care podría cambiar las normas o acciones descritas en este aviso. Si hiciéramos cambios, le notificaríamos sobre los mismos. Le diríamos el por qué de los cambios. Y le enviaríamos un nuevo Aviso de Privacidad en el que le indicaríamos los cambios. Cumpliríamos con las nuevas normas en lo referente a toda la información que tuviéramos sobre usted y entraría en efecto la fecha en la que el cambio fuera efectuado.

Quejas
Si usted piensa que sus derechos de privacidad han sido violados, puede quejarse a Preferred Care.  Las quejas deben ser mandadas a: Attn: Privacy Officer, Preferred Care, 220 Alexander St., Rochester, NY 14607.  No tomaremos medidas contra nadie que mande una queja. 

• Si desea una copia completa de sus reglas de privacidad, por favor llame a Servicios para Miembros (Member Services) al (585) 325-3113 o al (800) 950-3224.
• Si utiliza equipo auditivo (TTY), llame al (585) 325-2629 o al (800) 252-2452.
• O, pueden escribir a nuestro Oficial de Privacidad de Preferred Care, o venir a nuestras oficinas ubicadas en 220 Alexander St., Rochester, NY 14607.

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Member Rights & Responsibilities

Rights

As a member of Preferred Care, you have a right to:

• Be cared for with respect, without regard for health status, sex, race, color, religion, national origin, age, marital status, or sexual orientation.
• Be told where, when, and how to get the services you need from Preferred Care.
• Be told by your PCP what is wrong, what can be done for you, and what will likely be the result in language you understand.
• Get a second opinion about your care.
• Give your OK to any treatment or plan for your care after that plan has been fully explained to you.
• Refuse care and be told what you may risk if you do.
• Get a copy of your medical record, and talk about it with your PCP.
• Be sure that your medical record is private and will not be shared with anyone except as required by law, contract, or your OK.
• Use Preferred Care’s complaint system to settle any complaints, or you can complain to the NYS Department of Health or your local Department of Social Services any time you feel you were not treated fairly.
• Use the State Fair Hearing system.
• Appoint a relative or friend to speak for you if you are unable to speak for yourself about your care and treatment.

Responsibilities

As a member of Preferred Care, you agree to:

• Work with your PCP to guard and improve your health.
• Find out how your health care system works.
• Listen to your PCP’s advice and ask questions when you are in doubt.
• Call or go back to your PCP if you do not get better, or ask for a second opinion.
• Treat health care staff with the respect you expect yourself.
• Call Member Services if you have problems with any health care staff. 
• Keep your appointments.  If you must cancel, call as soon as you can.
• Use the emergency room only for real emergencies.
• Call your PCP when you need medical care, even if it is after hours.

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Derechos y responsabilidades de los asociados

Derechos

Como miembro de Preferred Care, usted tiene derecho a:

• Ser tratado con respeto y dignidad, independientemente de su condición médica, sexo, raza, color, religión, origen, edad, estado civil u orientación sexual.
• Recibir información acerca de dónde, cuándo y cómo obtener los servicios que necesita de Preferred Care.
• Recibir información de su PCP acerca de su problema de salud, los tratamientos disponibles y el resultado probable, de manera clara y con un lenguaje que usted comprenda.
• Obtener una segunda opinión sobre su condición y tratamiento.
• Autorizar todo tratamiento o plan para su atención médica una vez que el plan le haya sido explicado en su totalidad.
• Rechazar un tratamiento y recibir información sobre los riesgos derivados de tal acción.
• Obtener una copie de su legajo médico y discutirlo con su médico primario.
• Asegurarse de que su legajo médico es privado y que no sera compartido con nadie a menos que así se requiera por ley, por contrato o cuando usted lo autorice.
• Usar el sistema para presentación de quejas de Preferred Care para resolver cualquier disputa, o presenter so queja su queja al Departamento de Salud del Estado de Nueva York o a la oficina local del Departamento de Servicios Sociales si usted cree que no ha sido tratado con justicia.
• Utilizar el sistema estatal de Revisión Imparcial.
• Designar a un familiar o un amigo para que exprese sus deseos en cuanto a atención y tratamientos si usted está incapacitado para hacerlo por sí mismo.

 Responsabilidades

Como miembro de Preferred Care, usted se compromete a:

• Trabajar con su médico primario (PCP) para mantener y mejorar su salud.
• Informarse de cómo funciona su sistema de atención médica.
• Escuchar los consejos de su PCP y hacer preguntas cuando tenga dudas.
• Llamar a su PCP o volver a su consultorio si no experimenta mejoría, o buscar una segunda opinión.
• Tratar al personal de atención médica con el respeto con el cual usted espera ser tratado.
• Hacernos saber si tiene problemas con algún proveedor de atención médica.  Llame al departamento de Servicios a Asociados.
• Respetar los turnos concertados.  Si debe cancelar una visita, llame y notifique al médico tan pronto como sea possible.
• Usar la sala de emergencia únicamente para emergencies verdaderas.
• Llamar a su PCP siempre que necesite atención médica, aún cuando sea fuera del horario de atención.

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How to File a Complaint (Grievance)

1.) You can file a complaint by phone if:

• We have denied access for a referral
• We have told you a service is not covered

 To file a complaint by phone, call Member Services at (585) 327-2470 or (800) 852-7826.  TTY users may call (585) 325-2629 or (800) 252-2452.  Representatives are available Monday – Friday from 7:00 a.m. to 8:00 p.m. Eastern Time.  If you call us after hours, please leave a message.  We will call you back the next working day.  If we need more information to make a decision, we will tell you.  If needed, we will ask you to sign a written statement of your phone complaint.  This puts the basic facts of your complaint on record and makes your concerns clear.  After your call, we will send you a form which outlines your complaint.  If you agree with our summary, you should sign and return the form to us.  If you disagree with the summary, please write down the correct information on the form.  Then sign the form and return it to us. 

2.) You can file a written complaint for other concerns:

• By writing us a letter
• By asking us for a complaint form to fill out.  (To get a complaint form, call us at (585) 327-2470 or (800) 852-7826, or for TTY call (585) 325-2629 or
  (800) 252-2452

• Mail your complaint (form or letter) to:

                            Preferred Care

                            220 Alexander St.

                            Rochester, NY 14607

• Fax the complaint to (585) 327-2298

 What happens next

After we get your complaint, we will send you a letter within 15 working days.  We will tell you:

•      Who is working on your complaint,
•      How to contact this person, and
•      If we need more information.

 After we get all the information we need:

• When a delay would risk your health, we will call you with our decision in 48 hours.  Then we will send you a letter in three (3) working days.
• If it is about a referral or benefits, we will tell you our decision in writing in 30 days.
• For all other complaints, we will tell you our decision in writing in 45 days.

 All clinical decisions will be made by qualified clinical personnel.  When we call or write you about what we decide, we will tell you the reasons.  We will also tell you how to appeal our decision and include any forms you need.

You may also file a complaint anytime by calling:

•      New York State Department of Health at 1-800-206-8125, or
•      Your local department of social services

•      Or by writing to:

            NYS Department of Health

           Bureau of Certification and Surveillance

           Corning Tower

          Albany, NY 12237

We will give you the reasons for our decision and clinical rationale, if it applies.

Appeals

If you are not satisfied with what we decide, you have at least 60 business days after hearing from us to file an appeal.  You must appeal in writing (or by using Preferred Care’s form).  Call Member Services at (585) 327-2470 or (800) 852-7826.  TTY users may call (585) 325-2629 or (800) 252-2452.

We will send you a letter within 15 working days.  The letter will tell you:

• Who is working on your appeal,
• How to contact this person, and
• If we need more information.

Your appeal will be decided by:

• Licensed, certified, or registered health care professionals when the appeal is about a clinical matter.  These will be people who did not work on your complaint.
• Persons who work at a higher level than the people who worked on your complaint for all other appeals.

After we get all the information we need:

• When a delay would risk your health, we will let you know our decision in two (2) business days.
• For all other appeals, we will let you know our decision in 30 days.

You may also file a complaint anytime by calling:

• New York State Department of Health at 1-800-206-8125, or your local Department of Social Services:
• Genesee County:        (585) 344-2580
• Livingston County:       (585) 243-7300
• Monroe County:           (585) 274-6000
• Ontario County:           (585) 396-4599

You also may write to the NYS Department of Health, Bureau of Certification and Surveillance, Corning Tower, Albany, NY 12237.

Billing Complaints

If you have any problems receiving bills for services that should be paid by Preferred Care, call Member Services at (585) 327-2470 or (800) 852-7826.  TTY users may call (585) 325-2629 or (800) 252-2452.  A Preferred Care representative will help you.  If you have problems receiving bills for services that should be paid by Medicaid, call your local Department of Social Services.

Fair Hearings

New York State Fair Hearings

In some cases, you may ask for a fair hearing from New York State.  Some of those cases are:

• You are not happy with a decision about staying in or leaving the Preferred Care  plan made by your local Department of Social Services or the New York State Department of Health. 

• You are not happy about a decision that Preferred Care made about medical care you were getting.  You may feel the decision stops or limits your Medicaid benefits.  Or, you may feel Preferred Care did not make a decision in a reasonable amount of time.  

• You are not happy with a decision Preferred Care made that told you that you couldn’t get medical care you wanted.  You may feel the decision limits your Medicaid benefits. 

• You are not happy with a decision made by your doctor not to order the services you wanted.  You may feel that the doctor’s decision stops or limits your Medicaid benefits.  In this case, you have to file a complaint and an appeal with Preferred Care.  If Preferred Care agrees with your doctor, you may ask for a fair hearing by New York State.

Remember, you can complain to the New York State Department of Health by calling 1-800-206-8125.

In some cases, you can keep getting your care the same way while you wait for your fair hearing.  If you have questions, please call Preferred Care Member Services at (585) 327-2470 or (800) 852-7826.  TTY users may call (585) 325-2629 or (800) 252-2452.

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Cómo presentar una queja (Reclamo)

1.) Usted puede presenter una queja por teléfono si:

• Hemos negado el acceso para una orden de consulta.
• Le homos informado que un servicio no está cubierto.

Para radicar una queja por teléfono, llame al departmento de Servicios a Asociados a los teléfonos (585) 327-2470 o (800) 852-7826; si utiliza equipo auditivo (TTY), llame al
(585) 325-2629 o al (800) 252-2452 de lunes a viernes de 7:00 a.m. a 8:00 p.m. (Hora del este del país).  Si llama fuera de este horario, puede dejar un mensaje.  Nos communicaremos con usted el siguiente día hábil.  Si necesitamos más información para tomar una decisión, se lo hareemos saber.  De ser necesario, le pediremos que firme una declaración escrita de su queja telefónica.  Este documento registra los puntos básicos de su queja y aclara sus inquietudes.  Luego de su llamada, le enviaremos un formulario que describe su queja en forma general.  Si usted está de acuerdo con el contenido, escriba la información correcta en el formulario, fírmelo y devuélvalo a nuestras oficinas. 

2.) Si se trata de motivos diferentes a los enunciados en el punto 1), usted puede presenter una queja por escrito

• Enviándonos una carta, o
• Solicitando un formulario de quejas (para obtener un formulario de quejas, llame al (585) 327-2470 ó al (800) 852-7826; si utiliza equipo auditivo (TTY), llame al (585) 325-2629 ó al (800) 252-2452

• Envíe la queja escrita (formulario o carta) a:

     Preferred Care

     220 Alexander St.

     Rochester, NY 14607

• Atravez del fax al (585) 327-2298

Qué sucede a continuación

Una vez que recibimos su queja, le enviaremos una carta dentro de los 15 días hábiles.

• Quién está trabajando en su queja,
• Cómo ponerse en contacto con esa persona, y
• Si necesitamos más información.

        Una vez que recibimos toda la información requerida:

• En los casos en que una demora pondría en riesgo su salud, lo llamaremos para informarle de nuestra decisión en 48 horas.  Además, le enviaremos una carta en 3 días hábiles.
• Si se trata de una orden de consulta o beneficios, le informaremos de nuestra decisión por escrito dentro de los 30 días.
• Paralas demás apelaciones, le informaremos de nuestra decisión dentro de 45 días.

Todas las decisións clínicas serán tomadas por personal clínico calificado.  Cuando le informemos de nuestra decisión, le haremos saber los motivos.  También le explicaremos cómo apelar nuestra decisión y le enviaremos todos los formularios necesarios.

Usted puede quejarse a cualquier tiempo llamando al:

• Departamento de Salud del Estado de Nueva York al 1-800-206-8125
• Su Departamento local de Servicios Sociales
• O escribiendo a:

NYS Department of Health

Bureau of Certification and Surveillance

Corning Tower, Albany, NY 12237

Apelaciones

Si no está satisfecho con nuestra decisión, tiene un plazo de al menos 60 días hábiles luego de recibir nuestra notificación para presenter una apelación.  La apelación debe ser presentada por escrito (o en el formulario de Preferred Care).  Llame al departamento de Servicios a Asociados, (585) 327-2470 ó al (800) 852-7826; si utiliza equipo auditivo (TTY), llame al (585) 325-2629 o al (800) 252-2452 de lunes a viernes de 7:00 a.m. a 8:00 p.m. (Hora del este del país).

Le enviaremos una carta dentro de 15 días hábiles.  En ella le informaremos:

• Quién está trabajando en su apelación,
• Cómo ponerse en contacto con esa persona, y
• Si necesitamos más información.

Su apelación será decidida por:

• Profesionales del áarea de salud certifcados, registrados o licencidaos, cuando se trate de asuntos clínicos.  Estos profesionales serán individuos quo no han valuado su queja.
• Para todas las otras apelaciones, personas que se desempeñan en un nivel superior al de quienes evaluaron su queja.

Una vez que recibimos toda la información requerida:

• En los casos en que una demora pondría en riesgo su salud, le informaremos de nuestra decisión en 2 días hábiles.
• Para las demás apelaciones, le informaremos de nuestra decisión en un plazo de 30 días.

Nosotros le daremos las decisións con las rezones clinicas, si es aplicable.  Si todavia no esta satifecho, puede presentar una queja en cualquier momento llamando al:

• Departamento de Salud del Estado de Nueva York al teléfono 1-800-206-8125, o a su oficina local del Departamento de Servicios Sociales:
• Departamento de Servicios Sociales del Condado de Genesee:     
  (585) 344-2580
• Departamento de Servicios Sociales del Condado de Livingston:  
  (585) 243-7300
• Departamento de Servicios Sociales del Condado de Monroe:       
  (585) 274-6000
• Departamento de Servicios Sociales del Condado de Ontario:       
  (585) 396-4599

Usted tambien puede escribir a NYS Department of Health, Bureau of Certification and Surveillance, Corning Tower, Albany, NY 12237.

Quejas Sobre Facturación

Si experimenta algún problema con las recepción de facturas por servicios que deberían ser pagados por Preferred Care, communíquese con nuestro departamento de Servicios a Asociados a los teléfonos (585) 327-2470 ó al (800) 852-7826; si utiliza equipo auditivo (TTY), llame al (585) 325-2629 ó al (800) 252-2452.  Un representante de Preferred Care lo asistirá.  Si experimenta problemas con la recepción de facturas por servicios que deberían ser pagados por Medicaid, llame a la oficina local del Departamento de Servicios Sociales.

Revisiones Imparciales

Revision Imparcial del Estado de Nueva York—En algunos casos, usted puede pedir una revision imparcial del Estado de Nueva York.  Algunos de esos casos son:

• Usted no esta feliz con una decisión acerca de permanecer o de apartarse del plan de Preferred Care hecho por su departamento local de servicios sociales o el Departamento de Salud del Estado de Nueva York.
• Usted no es feliz con una decisión que tomo Preferred Care acerca del cuidado médico que usted obtenía.  Usted puede sentirse que la decisión para o limita sus beneficios de Medicaid.  O, usted puede sentirse que Preferred Care no tomó un decisión en una cantidad de tiempo razonable.
• Usted no es feliz con una decisión que Preferred Care hizo que le dijo que usted no podia obtener el cuidado médico que usted quiso.  Usted puede sentirse que la decisión limita sus beneficios de Medicaid.
• Usted no es feliz con una decisión hecha por su doctor de no ordenar los servicios que usted quiso.  Usted puede sentirse que la decisión de su doctor para o limita sus beneficios de Medicaid.  En este caso, usted, tiene que archivar una queja y una apelación con el plan de Preferred Care.  Si Preferred Care concuerda con su doctor, usted puede pedir una revision imparcial por el Estado de Nueva York.

Recuerdo, usted puede quejarse al Departamento de Salud del Estado de Nueva York llamando al 1-800-206-8125.

En algunos casos, usted puede seguir recibiendo su cuidado de la misma manera mientras usted espera su revision imparcial.  Por favor llame a Servicios a los Miembros de Preferred Care al (585) 327-2470 o al (800) 852-7826; si utiliza equipo auditivo (TTY), llame al (585) 325-2629 ó al (800) 252-2452.

(De nuevo a tapa)

Last Revised: June 2005
Last Reviewed: December 2005