Preserving Confidentiality for Members

PROTECTION OF PRIVACY IN ALL SETTINGS

It is the right of Western Health Advantage (WHA) members to have information regarding their health care benefit plan and medical records treated as confidential. WHA employees, and the employees of those contracted to provide services to WHA members, are legally and ethically obligated to protect the privacy of member information and prevent its unauthorized use, disclosure, or inappropriate destruction. WHA employees are apprised of the Plan's confidentiality policies and sign a confidentiality agreement as a condition of employment. In addition access to, and use of, member information is limited to those with a need to know for business reasons, electronic databases are password protected, physical security measures exist, and the process for exchanging information between Plan and providers has security measures in place.

SYSTEM GENERATED ID CARDS

Member's will be receiving new identification cards in late September. To better serve our members privacy, WHA will issue system-generated member identification (ID) numbers, which will replace our member's current social security number member identification.

MEMBER INFORMATION COLLECTED BY WHA

WHA collects and maintains personal and medical information from members for enrollment purposes, to measure customer satisfaction, carryout medical underwriting for determining individual eligibility, make coverage determinations, resolve coverage disputes, and to pay claims for health care services that have been delivered.

WHA adheres to all state and federal laws governing the use and disclosure of member information. California state laws provide for the routine use and disclosure of health care information by licensed health care plans for carrying out their key business functions. Requests for the release of information, beyond that provided for by law, are accommodated only when specifically authorized by the member or the member's representative.

ROUTINE CONSENT FOR USE/DISCLOSURE

Members sign a routine consent at the time of enrollment with WHA. A routine consent covers all adults and dependents for as long as they have covered health care services under WHA. A routine consent allows WHA to use and disclose medical information to carry out key business functions, including but not limited to:

• Enrollment, billing and claims management
• Resolving member grievances and appeals
• Quality review and improvement activities
• Health Plan licensing and accreditation reviews
• Provider reimbursement
• Coverage determinations
• Medical data processing

SPECIAL CONSENT FOR DISCLOSURE

California state laws require special consents in certain situations. Special consents provide the member the opportunity to approve or deny the release of their information in areas that fall outside the limits of the routine consent. Special consents are required for the disclosure of HIV test results, alcohol and substance abuse data, information regarding inpatient and outpatient mental health services, genetic characteristics testing, exchange of behavioral health information between a behavioral health provider and a member's PCP, requests for information related to workers' compensation or auto insurance claims, prior to participation in a research study, and in situations where a release of information might result in the member being contacted by an organization for marketing purposes.

MEMBERS WHO ARE UNABLE TO GIVE CONSENT

When consent is required and the member is unable to give consent for release of records, medical information will be released by WHA only when a specific written authorization is received from the member's legal representative.

USE OF MEASUREMENT DATA

Claims and encounter data is used to make assessments about the quality of medical services provided to members. Individually identifiable information cannot be used in these reports. WHA's disease management programs also use claims information to identify members with chronic conditions who might benefit from such programs.

INFORMATION FOR EMPLOYERS

Unless specifically authorized by the member, WHA does not release any medical information to an employer that would directly or indirectly indicate that an employee is receiving or has received services from a WHA provider.

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