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WVFH Members

Member Rights


Member Rights

As a member of WVFH, you have rights around your health care. You have the right to:

  1. Get member rights and responsibilities and learn about them.
  2. Get help you need to understand your benefits.
  3. Get information about us, our services, doctors, other providers. You should have access to services that are needed when services are accessible to you.
  4. See your medical records (request and get a copy within 30 days of request or have it amended within 60 days).
  5. Have your medical records kept private. You must tell us in writing that it is OK for us to share them by law.
  6. Get complete facts from your doctor relating to your condition or treatment plan.
  7. You can inspect and offer corrections to your own medical records, and request a copy of your records.
  8. Be part of honest talks about your needs and treatment options. This is your right no matter the cost and whether your benefits cover them. Be part of decisions that are made about your health care needs.
  9. Be told about other treatments or plans for care in a way that fits your condition. You can get information about other courses of care in an understandable form.
  10. Get news about how doctors are paid.
  11. Find out how we decide if new technology or treatment should be part of a benefit.
  12. Be treated with respect, dignity and the right to privacy all the time.
  13. Talk to your doctor about private things.
  14. Have problems taken care of fast. This includes things you think are wrong like issues about your coverage, getting an approval from us, or payment of service.
  15. Be treated the same as others.
  16. Get care that should be done for medical reasons. We must furnish health care services specified in this contract.
  17. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
  18. Choose your PCP from our Provider Directory that is taking new patients.
  19. Use providers who are in our network - choose from among those affiliated with WVFH.
  20. Get medical care in a timely manner.
  21. Get services from providers outside our network in an emergency.
  22. Be able to make choices about your care. You can participate in decision-making, including the right to refuse treatment or care from your PCP or other caregivers.
  23. Be able to obtain a prompt resolution of issues raised. This includes complaints, grievances, or appeals and issues related to authorization, coverage, or payment of services.
  24. Make an Advance Directive (also called a Living Will).
  25. Tell us your concerns about WVFH and the services you get.
  26. Question a decision we make about coverage for care you got from your doctor.
  27. File a complaint or an appeal for any care you get or if your language needs are not met.
  28. Ask how many grievances and appeals have been filed and why.
  29. Tell us what you think about your rights and responsibilities. You can suggest changes.
  30. Offer suggestions for changes in policies and procedures.
  31. Ask about our Quality Improvement Program. You can tell us how you would like to see changes made.
  32. Ask about our Utilization Review process. You can give us ideas on how to change it.
  33. You should know that WVFH uses the date you joined the health plan to decide your benefits.
  34. Know that we only cover services that are part of your plan.
  35. Know that we can make changes to benefits as long as we tell you about the changes in writing.
  36. Ask for this member handbook and other member materials in other formats at no charge to you. This includes other languages, large print, audio CD or Braille.
  37. Ask for an oral interpreter and translation services in all non-English languages at no cost. You can call Member Services for help. This includes all languages of the major population groups served.
  38. Use interpreters who are not your family members or friends.
  39. Know you are not liable if your Plan becomes bankrupt (insolvent).
  40. Know your provider can challenge the denial of service with your approval.
  41. Know you can request a copy of the member handbook at any time. You will be notified annually of your right to request a handbook.
  42. Know how you can get a list of providers in the network by calling member services. The list includes names, credentials, and education level of all network providers. You should know how you may choose providers within WVFH. You can call member services for help.
  43. Know you are free to exercise your rights. Exercising these rights does not adversely affect the treatment of the member.
  44. Get information in accordance with contract standards.
  45. Get a second opinion at no cost to you for a medical condition.
  46. Know that we, your doctors, and other providers cannot treat you in a different way because of your age, sex, race, national origin, language needs, or degree of illness or health condition. This includes your religion, mental or physical disability, sexual orientation, genetic information, source of payment, or if you are homeless.
  47. Refer yourself to in-network and out-of-network family planning services.
  48. Access certified nurse midwife services and certified pediatric or family nurse practitioner services.
  49. Get emergency post-stabilization services.
  50. Ask for a state fair hearing after a decision has been made about your appeal.
  51. Disenroll from the plan.
  52. Have your parent or a representative make treatment decisions when you can’t.

Member Responsibilities

As a member of WVFH, you also have some responsibilities:

  1. Tell us, your doctors, and other health care providers what we need to know to treat you.
  2. Learn as much as you can about your health issue and work with your doctor to set up treatment goals you agree on with your doctor.
  3. Ask questions about any medical issue. Make sure you understand what your doctor tells you.
  4. Follow the care plan and instructions that you have agreed on with your doctors or other health care professionals.
  5. Do things that keep you from getting sick.
  6. Make and keep medical appointments. Tell your doctor at least 24 hours in advance when you cannot make it.
  7. Always show your member ID card when you get services.
  8. Use the emergency room only in cases of an emergency or as your doctor tells you.
  9. If you owe a co-pay to your hospital, PCPs, or pharmacies, pay at the time the services are received.
  10. Tell us right away if you get a bill that you should not have gotten or if you have a complaint.
  11. Treat all WVFH staff and doctors with respect and courtesy.
  12. Know and follow the rules of your Health Plan.
  13. Know that laws guide your Health Plan and the services you get.
  14. Know that we do not take the place of workers’ compensation insurance.
  15. Tell your DHHR caseworker and us when you change your address, family status or other health care coverage.
  16. Call your PCP at any time when you need health care.
  17. Go back to your PCP or ask for a second opinion if you do not get better.
  18. Call Member Services at 1-855-412-8001 whenever anything is unclear to you or you have questions.

If a minor becomes emancipated (over the age of sixteen), or marries, he or she shall be responsible for following all WVFH member guidelines set forth above.