Right To Know

Benefits: Individuals have the right to be provided information from the purchasing entity (such as employer or union or public purchaser) and the insurance/third party payer describing the nature and extent of their mental health and substance abuse treatment benefits. This information should include details on procedures to obtain access to services, on utilization management procedures, and on appeal rights. The information should be presented clearly in writing with language that the individual can understand.

Professional Expertise: Individuals have the right to receive full information from the potential treating professional about that professional's knowledge, skills, preparation, experience, and credentials. Individuals have the right to be informed about the options available for treatment interventions and the potential effectiveness of the recommended treatment.

Contractual Limitations: Individuals have the right to be informed by the treating professional of any arrangements, restrictions, and/or covenants established between third party payer and the treating professional that could interfere with or influence treatment recommendations. Individuals have the right to be informed of the nature of information that may be disclosed for the purpose of paying benefits.

Appeals and Grievances: Individuals have the right to receive information about the methods they can use to submit complaints or grievances regarding provision of care by the treating professional to that profession's regulatory board and to the professional association. Individuals have the right to be provided information about the procedures they can use to appeal benefit utilization decisions to the third party payer systems, to the employer or purchasing entity, and to external regulatory entities.

  Confidentiality

Individuals have the right to be guaranteed the protection of the confidentiality of their relationship with their mental health and substance abuse professional except when laws or ethics dictate otherwise. Any disclosure to another party with be time limited and made with the full written, informed consent of the client. Individuals shall not be required to disclose confidential, privileged or other information other than diagnosis, prognosis, type of treatment, time and length of treatment, and cost.

Entities receiving information for the purpose of benefits determination, public agencies receiving information for health care planning, or any other organization with legitimate right to information will maintain clinical information in confidence with the same right and be subject to the same penalties for violation as is the direct provider of care.

Information technology will be used for transmission, storage or data management only with methodologies that remove individual identifying information and assure the protection of the individual's privacy. Information should not be transferred, sold, or otherwise utilized.

  Choice

Individuals have the right to choose any duly licensed/certified professional for mental health and substance abuse services. Individuals have the right to receive full information regarding the education and training of professionals, treatment options (including risks and benefits) and cost implications to make an informed choice regarding the selection of care deemed appropriate by individual and professional.

  Determination
  of Treatment

Recommendations regarding mental health and substance abuse treatment shall be made only by a duly licensed/certified professional in conjunction with the individual and his or her family as appropriate. Treatment decisions should not be made by third party payers. The individual has the right to make final decisions regarding treatment.

  Parity

Individuals have the right to receive benefits for mental health and substance abuse treatment on the same basis as they do for any other illnesses with the same provisions, co-payment, lifetime benefits and catastrophic coverage in both insurance and self-funded/self-insured health plans.

  Discrimination

Individuals who use mental health and substance abuse benefits shall not be penalized when seeking other health insurance or disability, life or any other insurance benefits.

  Benefit Use

The individual is entitled to the entire scope of the benefits within the benefit plan that will address his or her clinical needs.

  Benefit Design

Whenever both federal and state law and/or regulations are applicable, the professional and all payers shall use whichever affords the individual the greatest level of protection and access.

  Treatment Review

To assure that treatment review processes are fair and valid, individuals have the right to be guaranteed that any review of their mental health and substance abuse treatment shall involve a professional having the training, credentials and licensure required to provide the treatment in the jurisdiction in which it will be provided. The reviewers should have no financial interest in the decision and are subject to the section on confidentiality.

  Accountability

Treating professionals may be held accountable and liable to individuals for any injury caused by gross incompetence or negligence on the part of the professional. The treating professional has the obligation to advocate for and document necessity of care and to advise the individual of options if payment authorization is denied.

Payers and other third parties may be held accountable and liable to individuals for any injury caused by gross incompetence or negligence or by their clinically unjustified decisions.

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Copyright © 1999 The Psychotherapy Guild
Last updated May 1999.