The Plan is permitted to use and to disclose PHI in order to aid in your treatment, obtain payment for health care services provided to you and conduct our own “health care operations.” Under limited circumstances, we may be able to provide PHI for the health care operations of other providers and health plans. We may use your PHI for purposes of treatment, payment and health care operations without your authorization. At times it will be necessary for the Plan to share PHI with our Business Associates so that they may assist us with our health care operations. Specific examples of the ways in which PHI may be used and disclosed are provided below. This list is representative only and not every use and disclosure in a category will be listed.
Treatment: Although the Plan does not engage in treatment activities, we may disclose your PHI to a doctor or a hospital that asks us for it to assist them in providing you with treatment.
Payment: The Plan may use and disclose your PHI to pay claims from doctors, hospitals and other providers for services delivered to you that are covered by the Plan.
- Benefits and Claims: The Plan will use PHI and will disclose this information for billing, claims management and medical necessity review in order to fulfill our responsibility to provide coverage and health care benefits as well as to provide payment for health care services. For example, the Plan may use information it receives from a health care provider in order to process a claim. We will then send the Subscriber an Explanation of Benefits that contains PHI about the care provided to you. The Plan may also use and disclose PHI for billing and collection activities, including services provided by an outside billing agent or collection agency. In addition, we may share PHI with a billing agent who is assisting a health care provider.
- Enrollment and Eligibility: The Plan receives PHI including your name, address, Social Security number and birth date at the time of your enrollment. This “enrollment information” is used by the Plan to provide coverage for health care benefits and for eligibility determinations. We may share enrollment information with the “plan sponsor” of the Plan. Our plan sponsor is Kennett Consolidated School District.
- Coordination of Benefits, Adjudication, Subrogation: The Plan and other health plans use and disclose PHI to determine eligibility for benefits and periods of coverage. For example, if you are covered under another health plan (e.g., Medicare or a spouse’s policy) it may be necessary for the Plan to disclose PHI to the other plans in order to determine eligibility and pay claims correctly (coordination of benefits). Also, when processing a claim for health care benefits (adjudication), it may be necessary for the Plan to request information from, or share information with, a health care provider. The Plan may also share information with an automobile carrier or Workers’ Compensation carrier to determine third-party liability coverage (subrogation).
Health Care Operations: The Plan may use and disclose your PHI to rate our risk and determine our premiums for the health benefits it provides to you, to conduct quality assessment and improvement activities, to engage in care coordination or case management, and to properly conduct our business.
- Appeals and Complaints: The Plan may use and disclose PHI to investigate a complaint or process an appeal by a Member. In order to do so, it may be necessary for us to gather information or documents, including medical records that are held both internally and externally by the Plan or others. We may also share PHI with an independent medical reviewer to determine medical necessity and make recommendations to the Plan sponsor for use in the appeals process.
- Customer Service: We may provide PHI to a provider, a health care facility, or another health plan that contacts us with questions regarding your health care coverage, including questions concerning eligibility, claim status, effective dates of coverage, or other issues.
- Billing: We receive PHI such as name, address, Social Security number and birth date at the time of your enrollment. We may use this information to bill the Subscriber for the appropriate premiums. The information may also be used to reconcile billings we receive from our Business Associates for services provided to you.
Fraud and Abuse Detection and Compliance Programs: The Plan may use and disclose PHI for fraud and abuse detection and in activities required by our compliance program. We may also share this information with Health Oversight Agencies or other appropriate entities.
- Health Promotion and Disease Prevention: The Plan may use PHI to identify and contact you for population-based activities relating to improving health or reducing health care costs, such as information about disease management programs or about health-related benefits and services or about treatment alternatives that may be of interest to you.
- Litigation or When Required by Law: In the event that you are involved in a lawsuit or other judicial proceeding, the Plan may use and disclose PHI in response to a court or administrative order as provided by law. For example, we may be required to disclose PHI in response to a subpoena, warrant or other lawful process.
- Quality Improvement: The Plan may use or disclose PHI to help us evaluate our performance. For example, we may disclose names and addresses of our Members to a mailing house for use in mailing customer satisfaction surveys.
- Research and Reporting: The Plan may use your PHI in order to conduct an analysis of our data. This information may be shared with internal departments such as auditing or it may be shared with our Business Associates, such as our actuaries.
- Underwriting: The Plan may use and disclose PHI for underwriting, premium rating or other activities relating to the creation, renewal or replacement of contracts for health insurance.