Provider Rights & Responsibilities

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.