CCC Outreach Survey

Member Name * Member Number * Address * City * State * Zip *

Do you understand what providers are available to you? Yes No If no, please explain
Do you need assistance with choosing or changing your Primary Care Physician? (If yes, provide comments regarding assistance needed.) Yes No If yes, please explain
Do you understand your plans urgent or emergency care benefit? Yes No If no, please explain
Do you have questions about copayments, deductibles or coinsurance? Yes No If yes, please explain
Do you have any cultural or linguistic needs that we may address? Yes No If yes, please explain
Do you have any questions or special needs that have not been addressed in this survey? Yes No If yes, please explain
Are you aware of your appeal rights regarding claims and referral decisions? Yes No If no, please explain
Do you understand your plans out of area coverage? Yes No If no, please explain
Did you receive your enrollment packet that includes Member ID Card, Summary of Benefits and Member Handbook? Yes No Are there any items missing from your enrollment Packet? If so, please note the missing items:
Do you have any questions about your pharmacy co-pay's? Yes No If yes, please explain
Do you or your family have any special health needs? Yes No If yes, please explain
Why did you choose Lovelace Health Plan as your health plan provider? Cost Reputation Other Employee Offering Comments