How to navigate your health plan
Know your rights and learn about the health plan’s quality program.
To review your rights and responsibilities as a health plan member and to learn about the health plan’s quality program and goals, please click here. If you would like a printed copy of our quality program or a copy of your rights and responsibilities, please call Member Services. You may also find the rights and responsibilities (PDF) on the quality webpage.
Read your benefit information.
Your benefit documents and Summary of Benefits and Coverage are a good source of information.
The documents help you understand:
- The benefits and services you have
- The benefits and services you don’t have (exclusions)
- How to get your prescription drugs and what drugs are covered
- Your share of cost or ways you can pay for health care
- What to do if and when you need to submit a claim
- How to find out about participating providers
- What to do if you need care when you are out of town
- How and when to get routine, after-hours, specialty and emergency care
- How to voice a complaint or appeal a coverage decision
- How to get care from specialists, hospitals and mental health providers
If you need another copy of this information, please call the Member Services phone number on the back of your health plan ID card.
Know what to do if you have an issue.
We strive to meet your needs and want to know if you have an issue. If you are unhappy with services or care, or with the health plan in general, please call Member Services or write a letter to Sierra Health and Life. Either way, we will respond to your issue.
Know how to get information at your fingertips.
Did you know your health plan has online tools to help you? You can search our provider directory, search for covered medications in the prescription drug list and get personal benefit information in the online member center. The online member center can help you day or night and even on holidays.
Take advantage of these convenient service features to:
- Change your address
- Request replacement health plan ID cards
- Verify your coverage for pharmacy, dental or vision services
- Review the status of a claim
- Find out who is on record as your primary care physician
- Check the status of a prior authorization request
- Find out how much has been applied toward your calendar-year deductible, if applicable
Know that we research new medical technology.
For safety reasons, we formally evaluate new and emerging medical discoveries before including them in our member benefit package. Conducted by a highly skilled technical staff that includes physicians, our review process evaluates new technology against medical standards and clinical research to assess the effectiveness and safety of new medical procedures, drugs and devices. We also research new applications of existing technologies. If you, your providers or other interested parties would like to submit a request for the review of new medical technology, please contact Member Services.
Ask for help if you speak another language.
If you need help with communication, such as the services of a language interpreter, please call Member Services.
Know that the health plan does not offer incentives for prior authorization denials.
Sierra Health and Life prohibits the compensation of physicians, other health care professionals or staff to be based upon or used as an incentive for the denial of benefits. All decisions regarding your benefits are given special consideration based on your medical needs and the appropriateness of the care and service. Sierra Health and Life employees who perform utilization review duties do not receive any incentives, financial or otherwise, to encourage denial of benefits. That is, we provide no incentive for anyone on our team to restrict benefits for our members. For more information, please call Member Services.
Learn about internal and external review for denial of benefits.
If a benefit is denied, we provide internal review to help ensure member satisfaction in the medical decision-making process. Additionally, external independent review is provided by a panel of impartial medical professionals for eligible denials that have already undergone internal review. Expedited appeals are available when decisions are needed quickly. For additional information, please refer to your plan documents or call Member Services.
Know that we have special programs available for members.
Are you looking for extra help? You may be eligible for additional benefits from one of the programs below.
- Disease Management: If you have diabetes, kidney disease or asthma, you may be eligible to receive educational materials and calls from a registered nurse or health coach. For more information, call toll-free at 1-877-692-2059, TTY 711, on weekdays between 8 a.m. and 5 p.m.
- Complex Case Management: This program provides additional assistance for members with extra special needs. For more information, contact Member Services.
Know that we evaluate the care you receive.
If you are admitted to a non-contracted facility or receive care or services outside of the Sierra Health and Life service area, we may perform a retrospective review (after care was received) to evaluate the appropriateness of the medical care, services, treatments and procedures you received. As part of this process, we will review your medical records, admitting diagnosis and presenting symptoms. Keep in mind, access to non-emergency care outside of the contracted provider network or service area may not be covered and may incur additional expenses for you or your family.
We want to hear from you.
You may get a survey in the mail about your health plan. We need your help so we can monitor our plan and make improvements for our members.
Surveys you may get include the:
- Consumer Assessment of Healthcare Providers and Systems (CAHPS)
- Health Outcomes Survey (HOS) for Medicare members
- Patient Satisfaction Survey
- Disease Management Program Satisfaction Survey
- Complex Case Management Program Satisfaction Survey
- Telephone Advice Nurse Program Satisfaction Survey
Members are randomly selected for these surveys. If you get one, please fill it out. Your input is valuable to us.
Make an investment in your future.
It’s one that pays solid dividends, too. Keeping up with recommended health screenings may help your primary care provider take care of the little things — before they become more serious. At your next appointment, please talk to your provider about screenings and recommendations. Depending on your medical history, your provider may have additional medical advice. Learn more about preventive services available to you.
Ask your provider about e-prescribing
Electronic prescribing and medical records have resulted in greater accuracy, better patient service and improved operational efficiency. Providers and members alike enjoy the convenience of such technology. Talk with your provider about e-prescribing your next prescription.
Get answers to your questions about your health plan
Our member guide provides a comprehensive overview about your health plan, tools and resources, and tips to help you get the most value from your benefits.
We protect your privacy
Your privacy is very important to us. To request a copy of our Notice of Privacy Practices, please call Member Services at the number on the back of your health plan ID card.
You're covered
Under the Women’s Health and Cancer Rights Act, also known as “Janet’s Law,” health plan members are entitled to benefits for medically necessary mastectomy treatment for any related conditions, such as lymphedema. For more information, call Member Services at the number on the back of your health plan ID card.
24/7 we’re on call
If you’re unsure about your condition, our 24/7 advice nurse may be able to help. Our nurse is available to answer questions, provide self-care advice and help you decide whether to seek virtual care, urgent care, emergency care, or schedule an appointment with your provider. Just call toll free 1-800-288-2264, TTY 711.
Health education and disease management programs
We offer classes and consultations in person, virtually and by phone on a wide variety of health topics to help you achieve your health goals. Work with a registered nurse, registered dietitian or licensed alcohol and drug counselor to receive the health education and support you need to live your healthiest life possible.
- Weight management
Open to members age 18+ interested in weight-loss support. - Child nutrition program
Open to members ages 5 to 17 with their parent/guardian who want personalized nutrition advice. - Diabetes program
Open to members age 18+ with Type 1, Type 2 or gestational diabetes. - Prediabetes program
Open to members age 18+ diagnosed with prediabetes. - Asthma support
Open to members age 5+ diagnosed with asthma. - Kidney health
Open to members age 18+ diagnosed with stage 3 chronic kidney disease. - Tobacco cessation program
Open to members who want to quit tobacco/nicotine.
Our health education and disease management programs are available at no additional cost to eligible members. To join or opt out of any of these programs, call toll-free 1-800-720-7253, TTY 711.
Cut down on the clutter
Sign in to the online member center or HPN & SHL app and select your communication preferences to receive certain notifications by email or text, such as when a new explanation of benefits (EOB) is available. Make sure to update your contact information too.
Questions about your health plan
Call the number on the back of your health plan ID card to speak with our Member Services team. Or sign in to the online member center.