Member Resources

Member Rights and Responsibilities

Member Rights:

a.      You have the right to receive up-to-date information about your health plan, benefits available, the health care professionals, hospitals and other providers that participate in this Plan’s PPO Network and your rights and responsibilities.

b.      You have the right to receive a copy of the Notice of the NALC Health Benefit Plan’s Privacy Practices that outlines your rights and how to designate a personal representative which allows the Plan to discuss your protected health information.

c.      You have the right to privacy and confidentiality of your protected health information in accordance with applicable laws.

d.      You have the right to be treated with courtesy, dignity, and respect.

e.      You have the right to access quality care, regardless of race, color, national origin, sex, age, or disability.

f.       You have the right to participate fully with your network providers in decision making.

g.     You have the right to receive an explanation of benefits describing the benefits we pay, as well as to be informed of the reason for any adverse determination on a claim for benefits, including the specific utilization review criteria, guidelines or benefit provisions used in the determination.

h.      You have the right to appeal our decision in accordance with the Disputed Claims Process in Section 3, 7 and 8 of the Plan brochure.

i.       You have the right to request further information concerning anything you do not understand.

j.       You have the right to know that utilization management decisions are based only on the appropriateness of care and your current coverage.  The NALC Health Benefit Plan does not reward network providers or others for denying coverage.

k.      You have the right to make suggestions and recommendations regarding the NALC Health Benefit Plan’s Member Rights and Responsibilities statement.

l.       You have the right to receive a prompt reply when you ask us questions or request information.

m.    You have the right to know that neither you nor your health care provider can be punished for disputing a claim.

n.      You have the right to refuse to participate in research.

o.      You have the right to receive complete information about your diagnosis, evaluation, treatment, and prognosis from your health care professional.

p.      You have the right to participate with your health care professional in health care decisions.

q.     You have the right to be heard. Our complaint handling process is designed to hear and act on your complaint, concern, suggestion, or grievance and provide a courteous, prompt response.

Member Responsibilities:

a.      Read the information the Plan provides you and ask us questions when you need to know more.

b.      Make sure you understand your benefits under the NALC Health Benefit Plan, including your costs for services as outlined in Section 4 of our brochure.

c.      Accept personal responsibility for any charges not covered by this Plan, if applicable.

d.      Provide information the Plan needs to process your claims (to the extent possible) including other health insurance coverage your family may have.

e.      Keep your provider informed about your medical history and your current health status including the medications you take so they can effectively treat you and manage your care. 

f.       Inform your provider about any living will, medical power of attorney, or other directive that could affect your care.

g.     Participate with your provider to understand your health condition and develop mutually agreed upon treatment goals to the degree possible.

h.      Follow your provider’s instructions and treatment plan, ask questions if you don’t understand them.

i.       Treat your health care provider, their staff and others respectfully and honestly.

j.       Voice your complaints, concerns, suggestions, or grievances to our Customer Service department and /or your health care provider.

k.      Make sure you obtain authorization required under the Plan for certain services.

For questions about how to exercise these rights, or to learn more about these responsibilities or our Plan generally, you can reach our Customer Service department at:

888-636-6252 or 703-729-4677

Or write to us at:

NALC HBP

20547 Waverly Court

Ashburn, VA 20149