RR Standards & Guidelines
Members’ Rights and Responsibilities (RR)

1.    Statement of Members’ Rights and Responsibilities (RR 1)

  • Does the plan have a written policy that states its commitment to treating members in a manner that respects their rights?
  • Does the policy state the plan’s expectations of members’ responsibilities?
2.    Distribution of Rights Statement to Members and
       Practitioners (RR 2)

  • Does the plan distribute to members and participating practitioners its policy on members’ rights and responsibilities?
3.    Policies for Complaints and Appeals (RR 3)

  • Does the plan have written policies and procedures for the timely resolution of member complaints and appeals?
4.    Subscriber Information (RR 4)

  • Does the plan provide written information about benefits and charges for which members are responsible, including co-payments?
  • Does the plan provide written information for members on how to obtain care?
  • Does the plan provide written information for members about how to file a complaint or appeal?
  • Does the organization provide interpreter or bilingual services for telephonic functions based on the needs of its members?
5.    Physician and Hospital Directories (RR 5)

  • Does the plan provide a searchable Web based directory of its physicians and hospitals?
  • Does the directory contain the most current information on each physician and hospital?
  • Does the plan test its directory for ease or use and understanding?
  • Is the directory available in other formats such as print and telephonic?
6.    Privacy and Confidentiality (RR 6)

  • Does the plan take steps to protect the privacy of members’ information and records?
  • Does the plan inform members, practitioners and potential members of these policies?
7.    Marketing Information (RR 7)

  • Do the plan’s marketing communications materials describe its procedures for approving or denying coverage; covered benefits, including pharmacy benefits; noncovered services; availability of practitioners and providers; and any applicable restrictions?
  • Does the plan monitor new members’ understanding of its procedures, and update its marketing materials accordingly?
8.    Delegation of Members’ Rights and Responsibilities (RR 8)

  • If the plan delegates member services activities to a third party, is the decision-making process—including the responsibilities of the plan and delegated party—clearly documented?
  • Does the plan evaluate and approve the delegated party’s ability to perform these services beforehand, and on a regular basis?



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