Complete Care Member Guide

30 Important plan documents Documents such as your plan Summary of Benefits and Evidence of Coverage provide the details of your coverage and benefits. You can find them by logging in to My Health OnLine and clicking on the Plan Documents tab. This guide is for informational purposes and is not intended to be an all-encompassing explanation of your coverage and benefits. For specific information about your coverage and benefits, refer to your Evidence of Coverage. If there are conflicts between the information contained in this guide and your plan documents, your plan documents dictate. To request printed materials or materials in an alternative format, contact us at the phone number on the back of your member ID card and our Health Care Concierge team will work with you to meet your needs. How we assess new medical technology UPMC for Life Complete Care is committed to making sure you get the safest, most effective care possible. That is why we regularly review new medical technologies, including health services, medical procedures, equipment, and treatments. To be considered for coverage, the new technology: • Must have final unrestricted market and regulatory approval from the appropriate government agency. • Must be backed by conclusive scientific evidence showing therapeutic value, safety, and efficacy. • Should lead to beneficial health outcomes that outweigh harmful effects. • Should improve health outcomes at least as much as existing technologies. Our utilization management policy Utilization management (UM) is the process we use to evaluate the medical necessity, appropriateness, and efficiency of the health care services you may receive. UPMC for Life Complete Care affirms that: • We are committed to your receiving the best possible care under your benefits and do not offer incentives to providers to restrict your care. • UM decisions are based only on the appropriateness of care under your benefit plan. • No financial incentives are given to our UM advisers to decide in favor of less medical care being used. For more information or to obtain a copy of the criteria we use to make a UM decision, call your Health Care Concierge team at the phone number on the back of your member ID card. Your rights and responsibilities Visit upmchealthplan.com/medicare/documents- and-forms under the Appeals and Grievances tab to view a copy of UPMC Health Plan’s Member Rights and Responsibilities document. To receive a paper copy, call Member Services at the phone number on the back of your member ID card. Resolving problems Not satisfied with a decision UPMC for Life Complete Care has made regarding your coverage or with the health care services you received? You have the right to file a complaint or grievance. You can: • Call your Health Care Concierge at the phone number on the back of your member ID card. • Send written complaints to UPMC Health Plan, Complaints and Grievances, PO Box 2939, Pittsburgh, PA 15230-2939. • Visit upmchealthplan.com for complete details on the complaints and grievances process or refer to your Evidence of Coverage.