Members
Requesting Guidant MSO Policies and Procedures
During Business Hours: (888) 338-9665
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After-Hours: Contact the UM Department at (888) 338-9665 Option 1 (toll-free). Policies will be delivered within five business days from the request date.
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Telecommunications Relay Services (TRS)
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TRS allows individuals with hearing or speech disabilities to use the telephone system via a text telephone (TTY). Simply dial 711 to connect automatically to a TRS operator. It’s fast, functional, and free. Dialing 711 enables a call from any telephone in the United States, without needing a seven or ten-digit access number.
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Video and Internet-Based Relay Services
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711 dialing access does not support Video Relay Service (VRS), Internet Protocol (IP) Relay, or IP Captioned Telephone Service (IPCTS) Relay calls. To initiate a VRS or IP Relay call, hearing persons should call the provider’s 800 number. IPCTS users should dial their party directly; a communications assistant will automatically connect to the call.
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Reporting Compliance, Fraud, Waste, or Abuse Concerns Anonymously
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Compliance Anonymous Toll-Free Hotline (24/7): (877) 921-0123
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Member Rights and Responsibilities
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Guidant MSO is committed to ensuring your rights are respected and encourages you to uphold your responsibilities for a satisfying membership experience.
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Rights
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Non-Discrimination: You have the right to exercise your rights without discrimination based on race, ethnicity, national origin, religion, sex, age, disability, sexual orientation, genetic information, or source of payment.
Respect and Privacy: You are entitled to be treated with respect and dignity, and to have your privacy protected.
Information Access: You have the right to receive clear information about your IPA, its services, and the healthcare delivery process.
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Pre-Service Coverage Information: You can request coverage decisions or information from your plan before receiving services.
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Provider Choice: You are allowed to choose your healthcare provider within the plan.
Transparency in Provider Compensation: You can inquire about how your doctors are paid, and your plan must provide this information.
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Primary Care and Specialist Access: You have 24-hour access to your primary care physician or a covering physician. Women can directly access a women’s health specialist for routine and preventive care without a referral.
Treatment Information: You are entitled to detailed information about your diagnosis, treatment options, risks, and recovery prospects in understandable terms.
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Participation in Decisions: You can actively participate in your healthcare decisions, including the right to refuse treatment, understanding the potential health impacts.
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Access to Records: You have the right to access your medical records as allowed by law.
Cost Information: Before incurring expenses, you can be informed of the costs of care and your financial obligations.
Bill Examination: You have the right to examine and receive explanations for bills related to services provided to you.
Conduct and Complaints: You can express opinions about your care or IPA, suggest improvements, and use a systematic approach for resolving complaints and grievances.
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Appeals and Grievances: You can request appeals to resolve disputes with your plan or file grievances regarding issues or concerns with your plan.
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PCP Changes: You can change your primary care physician by contacting your health plan.
Continuity of Care: You are guaranteed reasonable continuity of care and timely responses to service requests and questions.
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Advanced Directives: You can formulate advanced directives for healthcare.
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Representation
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These rights extend to anyone legally responsible for making healthcare decisions on your behalf. Members can be represented by parents, guardians, family members, or other conservators if they are unable to participate fully in their own treatment decisions.
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Notice of Privacy Practices
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Your Information. Your Rights. Our Responsibilities.
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This notice is effective February 2025. Please note that Guidant MSO (“Guidant”) never markets or sells personal information. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
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Your Rights
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You have the right to:
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• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we have shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
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Your Choices
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You have some choices in the way that we use and share information as we:
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• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
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Our Uses and Disclosures
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We may use and share your information as we:
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• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
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Member Rights
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In the course of administering your health care benefits, we collect various types of protected health information (“PHI”)from you and other sources, including other health care providers. This information may be used, for example, to decide wither we will pay for your care and to see if you are getting the right care; for utilization review; detecting fraud and abuse; reviewing the qualifications of health care professionals and fulfilling legal and regulatory requirements. When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
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Get an electronic or paper copy of your medical record:
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• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
• Guidant will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we will tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
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Ask us to limit what we use or share:
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• You have the right to ask Guidant to limit what we use or share. You must tell Guidant what information you do not want to share and who you do not want us to share your information with. We will review and consider your request. Guidant is not required to agree with your request if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we have shared information:
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• You can ask for a list (accounting) of the times Guidant shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
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Get a copy of this privacy notice:
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You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically, by calling Guidant MSO at 1-877-921-0123 or TTY (711). We will provide you with a paper copy promptly. You can also access this notice on our website at www.guidantmso.com/privacy-policy
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Choose someone to act for you:
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• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
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File a complaint if you feel your rights are violated:
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• You can file a complaint if you feel we have violated your rights by contacting:
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Guidant Health - Compliance Officer
39765 Date Street, Suite 102
Murrieta, CA 92563
Telephone: (877) 921-0123
Email: compliance@guidantmso.com
Regional Manager Office for Civil Rights U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
Voice Phone (800) 368-1019
FAX (415) 437-8329
TDD (800) 537-7697
Email: OCRComplaint@hhs.gov
Web: www.hhs.gov/ocr/privacy/hipaa/complaints/
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• We will not retaliate against you for filing a complaint.
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Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
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In these cases, you have both the right and choice to tell us to:
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• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
Our Uses and Disclosures
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How do we typically use or share your health information?
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We typically use or share your health information in the following ways.
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Treat you:
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We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization:
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We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
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Bill for your services:
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We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues:
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We can share health information about you for certain situations such as:
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• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
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We can use or share your information for health research.
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Comply with the law:
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We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
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Respond to organ and tissue donation requests:
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We can share health information about you with organ procurement organizations.
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Work with a medical examiner or funeral director:
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We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests:
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We can use or share health information about you:
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• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions:
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We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
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• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of this Notice
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We can change the terms of this notice, and the changes will apply to all information we have about you. The revised notice will be available upon request, in our office, and on our website.
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Affirmative Statement
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Guidant MSO employees who are in a position to review, conduct, or make medical decisions are not influenced by financial incentives, bonuses, or additional compensation relating to the quality of, access to, or utilization of health care services rendered to members. Physician reviewers are not rewarded for issuing denials of coverage. All decisions are reviewed using evidence-based criteria and guidelines, and/or based on the member’s Health Plan’s Evidence of Coverage benefits.
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To discuss denials, obtain an appeal, or discuss medical review criteria, please contact us at 888-338-9665. Access publicly available guidelines and criteria here.
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Click on the pdf link below for step-by-step instructions.