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Health Care Reform

Welcome to Coventry Health Care of Florida's resource library for health care reform. The documents below will help you understand what health care reform means to you.
 

Click here to visit Coventry's Health Care Reform Information Link

Grievances and Appeals

Grievances and Appeals policies are in place to ensure that we have effective procedures for addressing, documenting, and resolving complaints or appeals.

The grievance procedure is designed to provide prompt, meaningful and confidential resolution of member concerns regarding quality of care, physician behavior, office waiting times, claims payment, coverage of services, and other similiar matters. 

The appeals procedures give members the opportunity to ask us to review any matter related to:

  • Issues about the scope of coverage for health care services
  • Medical necessity of services requested
  • Denial of care/services/claim
  • Other adverse benefit determinations
Grievances and Appeals instructions can be found here. The form can be found here.
For more information on your Grievance and Appeals rights please call the customer service phone number that appears on your member ID card.

Financial Compensation – Doctors Make the Decisions

People sometimes do not understand Utilization Management (UM) programs. At Coventry Health Care, UM is a system for reviewing the care that has been provided to our members.

Our policy about payment for services is to make sure that decisions are made because they are what our policies say we will do. There are no financial incentives in the review process.

  • UM decision-making is based only on appropriateness of care and service and existence of coverage.
  • The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
  • Financial incentives for UM decision makers do not encourage decisions that result in under utilization.
Participating Provider Compensation Arrangements
There are several types of compensation agreements between the health plan and providers, the most common types of compensation arrangements are "captiation" and "fee for service".  Under a capitation arrangement, the provider is paid a monthly fee.  Other providers are paid an agreed upon fee for a particular type of service that is rendered.

How We Evaluate New Technology

Doctors and health care manufacturers are constantly developing new technologies. They can include anything from a new way to perform a procedure to a new use for a piece of equipment. So Coventry Health Care, Inc. established a system to review and evaluate new technologies.

When a new technology is presented to Coventry, we do a thorough review of existing literature. The opinion of experts in the field may be requested. They may also contact the accrediting body of the appropriate medical specialty.

Coventry compares the information against established criteria. Then we decide whether to provide coverage. All of our decisions are based on making sure you have the appropriate care and services. We continue to focus on providing our members with quality health care products.

Coventry Mobile App

Consider the advantages of the Coventry Mobile app to manage your health and benefits on your smarphone anytime, anywhere.

Member Handbooks

Commercial Member Handbook
CoventryOne Individual Member Handbook

Member Rights and Responsibilities

To ensure that our members are treated fairly, we have a list of member rights and responsibilities. We encourage you to become familiar with them. To view your member rights and responsibilities click here.

Your Privacy Matters

Coventry Health Care works hard to keep your personal and health information secure and private.
We need information about you to manage your benefits. We collect your information from many sources. And keeping your information safe is one of our most important jobs. We make sure that only people who need to use your information have access to it. We may use and share your information for:

  • Treatment
  • Payment
  • Health care operations

These uses are covered under state and federal laws. Our policies will reflect the most protective laws that apply to you.  You can view our Notice of Privacy Practices here.

Coventry's Quality Improvement Program

Coventry is committed to providing members with access to quality care and delivering programs and services that help them enjoy optimal health.  The Coventry Quality Improvement (QI) program supports this commitment by ensuring that all our services meet high standards of quality and safety and that each member has the best health plan experience possible.

Through the QI program, Coventry identifies opportunities for improvements and implements solutions that reinforce our commitment to quality, safety and service excellence.  Our four primary areas of focus are:
 

  • Member satisfaction
  • Safety of care
  • Healthplan services
  • Access and availability to network providers 
One tool we use to identify opportunities for improvement is the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.  CAHPS is a program of the U.S. Agency for Healthcare Research and Quality that collects information on members' experiences with the health care system.  The survey questions focus on a member's overall satisfaction with:
  • The health plan
  • Their doctor and specialists
  • The medical care they've received 
Each year, a third party vendor sends the CAHPS survey to a random sample of our member population.  We use the results of the survey to help develop goals for the Quality Improvement program  and implement initiatives to achieve these objectives.  You can view the 2013 CAHPS results here.

You can find out more about Coventry's Quality Improvement program here.

Preventive Care Guidelines

Prior-Authorization Rules

Prior-Authorization Form

Member Reimbursement Form

Foreign Member Reimbursement Form & Instructions

Women’s Health Information and Helpful Links

Coventry Health Care of Florida provides access to the preventive health information on this website as a value added service to our members.

The information obtained through various websites is not a replacement for professional health care.  For individual medical guidance, please consult with your physician.

When you are connected to another website via the Coventry website, you may be subject to privacy practices and policies that are different from those maintained by Coventry.

Coventry does not control, maintain, or have influence over their privacy practices and policies and is not responsible for the use of your personal information by these entities.  The links to other websites found on this site are provided strictly for your convenience, and should not be understood to imply an endorsement of or particular affiliation with any other entity.

Coventry does not assume any responsibility for monitoring the content of any other website.

The American Institute of Ultrasound in Medicine
The American Institute of Ultrasound in Medicine is an association dedicated to the safe and effective use of ultrasound in medicine.  This website offers information for both physicians and patients.
The Society for Maternal-Fetal Medicine

This website is dedicated to obstetricians and gynecologists who have additional formal education in maternal-fetal medicine.  The Society for Maternal-Fetal Medicine provides information on why a patient may wish to be referred to a maternal-fetal medicine specialist.

American Heart Association

The American Heart Association is a national voluntary health agency whose mission is to reduce disability and death from cardiovascular disease and stroke.

Women in Distress of Broward County
Women in Distress provides victims of domestic violence with safe shelter, crisis intervention and resources, and educates the community in order to Stop Abuse For Everyone (SAFE) through Intervention, Education and Advocacy.
New York Online Access to Health

NOAH provides access to high quality full-text consumer health information in English and Spanish that is accurate, timely, relevant and unbiased.

Mayo Clinic

The Mayo Clinic is a leading institution in medical information providing tools for healthier lives.  This is a great site for questions and answers.

Nabco.org
Nabco.org is a website providing information on breast cancer.
National Osteoporosis Foundation

The National Osteoporosis Foundation's mission is to prevent osteoporosis, to promote lifelong bone health, to help improve the lives of those affected by osteoporosis and related fractures, and to find a cure.

National Ovarian Cancer Coalition

The National Ovarian Cancer Coalition's mission is to raise awareness and promote education about ovarian cancer.  The Coalition is committed to improving the survival rate and quality of life for women with ovarian cancer.

The North American Menopause Society

Devoted to promoting women's health and quality of life through an understanding of menopause.  This site contains information on menopause, perimenopause, early menopause, menopause symptoms and long-term health effects of estrogen loss, and a wide variety of strategies and therapies to enhance health.

OBGYN.net - The Universe of Women's Health

OBGYN.net is an academic website regarding women's health issues.

March of Dimes

The March of Dimes website has information and links regarding pregnancy and newborn health education.

American Pregnancy Association

The American Pregnancy Association is a national health organization committed to promoting reproductive and pregnancy wellness through education, research, advocacy and community awareness.

La Leche League

La Leche League was founded to give information and encouragement, mainly through personal help, to all mothers who want to breastfeed their babies.  While complementing the care of the physician and other health care professionals, it recognizes the unique importance of one mother helping another to perceive the needs of her child and to learn the best means of fulfilling those needs.

Breastfeeding.com

Breastfeeding.com provides question and answer sections on many topics releated to breast feeding.

These health benefit plans have exclusions and limitations and terms under which they may stay in force or discontinued. For cost and complete details of coverage, contact Coventry Health Care of Florida, Inc. or your agent.
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