Provider Rights & Responsibilities

Practitioner Rights at Antidote Health Plan

At Antidote Health Plan (Antidote), we are committed to ensuring fairness and transparency throughout our credentialing and network participation processes. We want to ensure all healthcare providers and practitioners understand their rights concerning the information we use and any decisions that may affect their participation with us.

Your Right to Review and Correct Information

All healthcare providers and practitioners in our network have the right to review information Antidote obtains to evaluate your credentialing and/or recredentialing application. This includes data gathered from external primary sources such as the National Practitioner Data Bank (NPDB), Council for Affordable Quality Healthcare (CAQH), malpractice insurance carriers, and state licensing agencies. However, this right does not extend to reviewing references, personal recommendations, or other information protected by peer review.

You also have the right to correct any erroneous information submitted by another party, excluding references, personal recommendations, or peer-review protected material. If information obtained from primary sources differs from what you submitted, Antidote will inform you. To request the release of such information, you must submit a written request. Once you receive this information, you will have 30 days from the initial notification to provide a written explanation detailing the error or difference in information to our Credentialing Committee. The Credentialing Committee will then include this explanation as part of the credentialing or recredentialing process. We will document receipt of the corrected information in your credentialing file.

Your Right to Be Informed of Application Status

If you have applied to join our network, you have the right to be informed of the status of your application upon request.

The information Antidote will share includes information obtained from outside primary sources such as the National Practitioner Data Bank (NPDB), Council for Affordable Quality Healthcare (CAQH), malpractice insurance carriers, and state licensing agencies.

However, this right does not extend to reviewing references, personal recommendations, other information that is peer review protected, the checklist used to document verification dates and who completed the verifications or other sources of information that were obtained to meet verification requirements, or if federal or state law prohibits disclosure.

To obtain your application status, contact Antidote at credentialing@antidotehealth.com or 1-888-623-3195. Based on the method you request to obtain application status Antidote will respond via email or telephone. Additionally, if information is missing from your application, you, or the individual you designate to submit your credentialing information, may receive email inquiries from CAQH or Antidote’s NCQA accredited CVO, Medallion. It is your responsibility to ensure that you maintain an up-to-date CAQH profile, all required documents are uploaded and attested and authorize Antidote to access your profile.

Your Right to Appeal or Reconsider Adverse Credentialing Decisions

If you are an existing provider and your continued participation is declined due to adverse credentialing determinations for reasons such as appropriateness of care or liability claims issues, you have the right to request an appeal of the decision. Appeal requests must be submitted in writing within 30 days from the date of Antidote’s notice.

For new applicants who are declined participation, you may request a reconsideration within 30 days from the date of Antidote’s notice. All written requests for appeal or reconsideration should include additional supporting documentation that supports your case for participation in the network. Reconsiderations will be reviewed by the Credentialing Committee at their next regularly scheduled meeting or no later than 60 days from the receipt of your additional documentation, in accordance with state and federal regulations. Written requests to appeal or seek reconsideration of adverse credentialing decisions should be sent to the individual specified on your denial letter.

Provider Rights

To be treated by their patients who are Antidote members and other healthcare workers with dignity and respect.
To receive accurate and complete information and medical histories for members’ care.
To have their patients, who are Antidote members, act in a way that supports the care given to other patients and that helps keep the doctor’s office, hospital, or other offices running smoothly.
To expect other network providers to act as partners in members’ treatment plans.
To expect members to follow their health care instructions and directions, such as taking the right amount of medication at the right times.
To make a complaint or file an appeal against Antidote and/or a member.
To file a grievance on behalf of a member, with the member’s consent.
To have access to information about Antidote quality improvement programs, including program goals, processes, and outcomes that relate to member care and services.
To contact Provider Services with any questions, comments, or problems.
To collaborate with other health care professionals who are involved in the care of members.
To not be excluded, penalized, or terminated from participating with Antidote for having developed or accumulated a substantial number of patients in Antidote with high-cost medical conditions.
To collect member copays, coinsurance, and deductibles at the time of the service.

Provider Responsibilities

Providers must comply with each of the items listed below.

To help or advocate for members to make decisions within their scope of practice about their relevant and/or medically necessary care and treatment, including the right to:
- Recommend new or experimental treatments,
- Provide information regarding the nature of treatment options,
- Provide information about the availability of alternative treatment options, therapies, consultations, or tests, including those that may be self-administered,
- Be informed of risks and consequences associated with each treatment option or choosing to forego treatment as well as the benefits of such treatment options.
To treat members with fairness, dignity, and respect.
To not discriminate against members based on race, color, gender, national origin, limited language proficiency, religion, age, health status, existence of a pre-existing mental or physical disability/condition including pregnancy and/or hospitalization, the expectation for frequent or high-cost care.
To maintain the confidentiality of members’ personal health information, including medical records and histories, and adhere to state and federal laws and regulations regarding confidentiality.
To give members a notice that clearly explains their privacy rights and responsibilities as it relates to the provider’s practice and scope of service.
To provide members with an accounting of the use and disclosure of their personal health information in accordance with HIPAA.
To allow members to request restriction on the use and disclosure of their personal health information.
To provide members, upon request, access to inspect and receive a copy of their personal health information, including medical records.
To provide clear and complete information to members - in a language they can understand about their health condition and treatment, regardless of cost or benefit coverage, and allow member participation in the decision-making process.
To tell a member if the proposed medical care or treatment is part of a research experiment and give the member the right to refuse experimental treatment.
To allow a member who refuses or requests to stop treatment the right to do so, if the member understands that by refusing or stopping treatment the condition may worsen or be fatal.
To respect members’ advance directives and include these documents in their medical record.
To allow members to appoint a parent/guardian, family member, or other representative if they can’t fully participate in their treatment decisions.
To allow members to obtain a second opinion, and answer members’ questions about how to access health care services appropriately.
To follow all state and federal laws and regulations related to patient care and rights.
To participate in Antidote data collection initiatives, such as HEDIS® and other contractual or regulatory programs and allow use of provider performance data.
To review clinical practice guidelines distributed by Antidote.
To comply with the Antidote Medical Management program as outlined herein.
To disclose overpayments or improper payments to Antidote.
To provide members, upon request, with information regarding the provider’s professional qualifications, such as specialty, education, residency, and board certification status.
To obtain and report to Antidote information regarding other insurance coverage the member has or may have.
To give Antidote timely, written notice if provider is leaving/closing a practice.
To contact Antidote to verify member eligibility and benefits, if appropriate.
To invite member participation in understanding any medical or behavioral health problems that the member may have and to develop mutually agreed upon treatment goals, to the extent possible.
To provide members with information regarding office location, hours of operation, accessibility, and translation services.
To object to providing relevant or medically necessary services based on the provider’s moral or religious beliefs or other similar grounds.
To provide hours of operation to Antidote members which are no less than those offered to other commercial members.