Processing HIPAA Privacy Forms 2014-Sample

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Processing HIPAA Privacy Forms

Processing HIPAA Privacy Forms

February 25,1014

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HIPAA OverviewHIPAA Overview

This training course is designed to equip you with the necessary tools to properly process HIPAA Privacy Requests. During the two day training period we will:

• Familiarize you with HIPAA, the HIPAA Privacy Rule and various HIPAA Forms• The effects HIPAA has on Horizon BCBSNJ• Referring HIPAA Privacy Complaints• Detailed review of the HIPAA Personal Representative Form• Understand the different types of Personal Representative

Requests/Representation• Determine when a form is Valid or Invalid • Processing Valid and Invalid requests in UCSW• Processing Valid requests in NMS 2.10 & 2.23 and Nasco• Processing a verbal Personal Representative Request• Review various scenarios• Answer Questions• Provide a HIPAA Contact List

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What is HIPAA?What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996.

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addressed the security and privacy of health data. As the industry adopts these standards for the efficiency and effectiveness of the nation's health care system will improve the use of electronic data interchange.

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What is the HIPAA Privacy Rule?What is the HIPAA Privacy Rule?

The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically.

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What is the HIPAA Privacy Rule?What is the HIPAA Privacy Rule?

• The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization.

• The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections.

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How does this effect Horizon?How does this effect Horizon?

Horizon must treat a personal representative as the member. That includes a person who under applicable state law has authority to make health-related decisions on behalf of an adult or an emancipated minor. In addition, the Rules allow disclosures of private information (PI) to persons who are involved in the care or payment for the care of a member.

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How do we achieve this?

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HIPAA Privacy FormsHIPAA Privacy Forms

• Authorization for Disclosure of Protected Health Information• Request to Access Private Information• Request for Confidential Communications• Request for Termination of Confidential Communications• Request for Personal Representative• Request to Represent a Deceased Member• Request to Terminate Personal Representative• Other HIPAA Forms (Amendment to PI, Accounting of

Disclosures)**

**Refer to New OLI2 for all forms relating to privacy matters**

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Authorization for Disclosure of PHI *Authorization for Disclosure of PHI *

• The member requests that Horizon disclose specific PI to someone other than the member (third-party);

• Someone else (third-party) requests that Horizon disclose the member’s PI; or

• Horizon obtains a member’s permission to disclose his/her PI (in those circumstances that require an authorization).

*PHI Protected Health Information

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Access to Private Information FormAccess to Private Information Form

• A member can request access to his/her PI and obtain a copy.

• A HIPAA access request is a member’s right under the Privacy Rules. It is treated differently than a “routine” request for information, such as a request for a duplicate copy of an EOB or SOP.

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Request for Confidential CommunicationsRequest for Confidential Communications

• Horizon must approve a member’s reasonable request to receive PI at an alternate location, or by alternative means, IF he/she states that the disclosure to the normal location could endanger him/her.

• While Horizon will trigger processing based on an oral Confidential Communications request, the member must complete a written form as a follow up to his/her oral request.

• Set up an Alert in UCSW with a password — this is the only circumstance where you should set up passwords.

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Request for Personal Representative FormRequest for Personal Representative Form

This form is used by our members to appoint a personal representative.

If a member/individual contacts Member Services and verbally request the appointment of a personal representative, the CSR (Customer Service Representative) will inform the member/individual that such a request must be submitted to Horizon in writing using the Request for Personal Representative Form.

If the member states that the request is urgent, the CSR should also inform the member that the forms can be accessed from the Member Portal, and faxed back to the CSR to be processed.

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Request to Represent a Deceased MemberRequest to Represent a Deceased Member

• Allows a person to represent a deceased Horizon member.

• The person needs to attach legal documentation to prove his/her authority to represent the member’s estate. (e.g. Order of Probate, valid will, appointment as administrator; not Power of Attorney).

• If the person was already designated as the member’s Personal Representative prior to the member’s death, no new form is needed. (However, his/her representation must be changed if someone with a greater legal right to represent the deceased notifies us and requests to represent the deceased member.)

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Request to Terminate Personal Representative Request to Terminate Personal Representative

• Allows the member to terminate his/her designated or automatic personal representative. (e.g. spouse-to-spouse, parent-to-child)

• By terminating the Personal Representative, Horizon agrees not to disclose PI to that person. Thus, the verification procedure is critical, since that’s the way we will know not to disclose PI to that person!

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Referrals to HIPAA Privacy Team and Privacy OfficeReferrals to HIPAA Privacy Team and Privacy Office

All HIPAA Forms received, should be referred as follows:

• Department: HBC Appeals/ HIPAA/ Exec & Reg Complaints

• Team (Choose one of the following): CCU HIPAA Privacy Team Nasco Escalations should be e-mailed to the following mailbox:

• HIPAA Appeals Unit

***Note: Only Privacy Complaints should be referred to HBC Privacy Team. Detailed information on how to properly handle a privacy complaint can be found on New OLI under HIPAA/Privacy/Privacy Procedures/ Receiving and Handling Privacy Complaints and Violations – HIPAA ***

• Department: HBC Privacy Office• Team: Privacy Office• Assigned To: Privacy Office

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Request for Personal Representative FormRequest for Personal Representative Form

Under the Privacy Rules, Horizon must treat a personal representative as the member. That includes a person who under applicable state law has authority to make health-related decisions on behalf of an adult or an emancipated minor. In addition, the Rules allow disclosures of private information (PI) to persons who are involved in the care or payment for the care of a member. Horizon also treats them as personal representatives.

Generally, Horizon requires a member to designate a personal representative in writing, although it is Horizon’s policy to treat a spouse or parent on the coverage as a personal representative without any such

designation.

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Types of Requests for Personal RepresentationTypes of Requests for Personal Representation

• Request for Personal Representative Form

• Request to Represent a Deceased Member Form

• Request to Terminate Personal Representative Form

**Refer to New OLI to access current HIPAA Forms**

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Types Of RepresentationTypes Of Representation

• Limited Authority - The member appoints a person who can contact Horizon and receive the member’s PI.

• Full Authority - The member appoints a person who will receive the member’s correspondence, EOBs and checks. This requires setup of

an alternate address for the member.

NOTE: Reimbursement checks will, per our contracts, still be made payable in the

name of the subscriber, absent special circumstances.

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ScenariosScenarios

ITIT’’S YOUR TURNS YOUR TURN

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Case Study #1Case Study #1

Mrs. Jones calls and states “I no longer want my husband, who I am divorcing, to be my Personal Representative.

What is the correct form to send the member?

Answer: A Request to Terminate a Personal Representative Form

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Mr. Lin calls and states he is from an attorney's office and is seeking records related to a motor vehicle accident involving our member.

What form should be sent to Mr.Lin?

Answer: An Authorization for Disclosure of Protected Health Information Form

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Ms. McPhee complains that her appeal was denied by Horizon and that she wants a copy of her records.

What form should be sent to the member?

Answer: A Request to Access to Private Information Form

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Case Study #4ACase Study #4A

The caller states his grandmother, Mrs. Smith, (for whom he is the Personal Representative with limited authority) has passed away and he needs to take care of her affairs, including her insurance claims with Horizon.

What is the correct form to send caller?

Answer: No form is needed because the caller was the member’s Personal Representative prior to her death.

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Case Study #4BCase Study #4B

A second caller states she has never called before and she has been appointed as the Executrix for the same Mrs. Smith.

What is the correct form to send to caller?

Answer: Yes, but with limited authority.

Answer: Request to Represent a Deceased Member Form.

Can first caller still represent Mrs. Smith?

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Ms. Greer is calling on behalf of her mother. While being verified, she says that she is the daughter and her mother is in a nursing home. Her mother wants her to receive all of her correspondence.

What is the correct form to send to Ms. Greer?

Answer: A Request for Personal Representative Form

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Mrs. Williamson states that she is in danger if her husband discovers that she is going to have an abortion. She does not want her husband to find out.

What is the correct form to send to Mrs. Williamson?

Answer: A Request for Confidential Communications Form.

To what address should the form be sent?

Answer: To Mrs. Williamson’s alternate address.


Mary is the mother of Joseph who is a minor child who has his own single policy. By court order she is the residential custodial parent. She would like all correspondence sent to her address although Paul, the father premium payments. What form does she need to complete?

Answer: A Request for Personal Representative Form

Mary must complete the Request for Personal Representative Form and appoint herself with full authority so correspondence can be redirected to her address and supply all legal documentation.

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Susan is the parent of a minor child who has a single policy in which she pays the premium. She would like all correspondence sent to her address. What form does she

need to complete?

Answer: No form is required due to the Minor Child Verification Workflow that has been implemented and can be found on OLI2. As long as the mother can verify the identity of the child and advises she is the parent/guardian, the child’s PI can be disclosed to the mother. http://oli2.bcbsnj.com/Subsystems/HIPAA/Content/Privacy/Privacy_Procedures_HIPAA/Verification_Procedure_HIPAA.htm

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Case Study # 9Case Study # 9

A member calls to advise that received an EOB that does not belong to them. You document the inappropriate disclosure in UCSW. Where do you assign this service request?

Answer: Department: HBC Privacy OfficeTeam: Privacy OfficeAssigned To: Privacy Office

The HIPAA Team works closely with the Privacy Office with investigating privacy complaints and inappropriate disclosures, however, the function of the HIPAA Team is to process HIPAA Forms only. All Privacy Complaints should be forwarded to the Privacy Office for tracking/documenting purposes.

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Case Study # 10Case Study # 10

You received a call from an irate member who is seeking to have their personal representative form escalated. You have located the service request in UCSW. Who do you contact to escalate the request?

Answer: All HIPAA Escalations should be e-mailed to the HIPAA Appeals Unit ([email protected])

This is a dedicated mailbox which is monitored daily by a member of the HIPAA Appeals team.

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Processing HIPAA Privacy Forms 2014-Sample

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