Notice of Privacy Practices for the Use and Disclosure of Protected Health Information (PHI)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Western Health Advantage (“WHA”) is required by law to maintain the privacy of your health information and to provide you this Notice about our legal duties and privacy practices. We must follow the practices described in this Notice while it is in effect. This Notice takes effect August 12, 2016, and will remain in effect until we replace or modify it.
Protecting Your Privacy
At WHA, we understand the importance of keeping your health information confidential and we are committed to using your health information consistent with State and Federal law. WHA protects your electronic, written and oral health information throughout our organization. This Notice explains how we use your health information, and describes how we may share your health information with others. This Notice also lists your rights concerning your health information and how you may exercise those rights.
In the event your health information is disclosed in a manner not specified in this Notice, WHA will notify all affected individuals as required by law.
Protected Health Information (“PHI”)
For the purposes of this Notice, "health information" or "information" refers to Protected Health Information. Protected Health Information is defined as information that identifies who you are and relates to your past, present, or future physical or mental health or condition, the provision of health care, or payment for care. The information we use and share includes, but is not limited to:
- your name and address and other demographic information;
- personal information about your circumstances; and
- your past, present or future physical or mental health condition, the provision of health care to you and the past, present and future payment for the provision of health care; and your mental and physical medical history.
How We Use or Disclose Your PHI
We must disclose your PHI:
- To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this Notice; and
- To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected.
WHA uses and shares your health information for the purposes of treatment, payment, health care operations, and other uses permitted or required by Federal, State, or local law. In instances where your health information is not used for such purposes, WHA would require your written authorization prior to sharing it.
WHA may use or disclose your health information to health care providers (doctors, hospitals, pharmacies and other caregivers) who request it in connection with your treatment without your written authorization.
- We may share information with physicians, nurses, other health care professionals and facilities, and your medical group or hospital when necessary for you to receive appropriate care and treatment; for coordination or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another.
WHA may use and disclose your health information for the purposes of payment of the health care services you receive, without your written authorization. This may include claims payment, eligibility, utilization management, and care management activities.
- We may provide your eligibility information to your medical group so they are paid accurately and timely, or to a third party entity to ensure that your doctor or hospital is paid accurately and timely.
- We may provide information to the subscriber of a family policy or another individual for the purpose of handling or understanding medical bills, managing claims, reconciling your deductibles or out of pocket maximum payments, and the like.
- We may share information about you to a hospital or other health care provider to ensure that claims are billed properly.
Heath Care Operations
Health care operations are activities related to the normal business functions of WHA. WHA may use and disclose your PHI in order to administer our health plan and to support various business activities without your written authorization. For example, we may share information with others for any of the following purposes:
- Quality management and improvement activities in order to review and improve the quality of health care services you receive;
- Planning and general administration;
- Research and studies, such as member satisfaction surveys;
- Compliance and regulatory activities;
- Risk management activities;
- Population and disease management studies and programs; and
- Grievance and appeals activities.
In addition, under limited circumstances and in accordance with the law, WHA may use and disclose your PHI to support health care operations of health care providers or certain other entities contracted with WHA, if you have or had a relationship with that provider or entity.
Other Permitted Uses and Disclosures
WHA may use or disclose your health information without your written authorization, for the following purposes under limited circumstances:
- To State and Federal agencies that have the legal right to receive data, such as to make sure WHA is making proper payments and to assist Federal/State Medicaid programs;
- As required otherwise by Federal, State, or local law;
- For public health activities, such as reporting births, deaths, and disease, or disaster relief. We may provide coroners, medical examiners, and funeral directors information that relates to a person's death;
- For government healthcare oversight activities, such as fraud and abuse investigations and other legally appropriate health oversight activities; ;
- For judicial, arbitration, and administrative proceedings, such as in response to a court order, subpoena, or search warrant. For law enforcement purposes, such as providing limited information to locate a missing person;
- To a probate court investigator to determine the need for conservatorship or guardianship;
- For research studies that meet all privacy law requirements, such as research related to the prevention of disease or disability;
- To avoid a serious and imminent threat to health or safety;
- To contact you about new or changed benefits;
- To create a collection of information that can no longer be traced back to you;
- For purposes when issues concern child (including adult dependent) or elder abuse and neglect;
- For specialized government functions, such as providing information for national security and military activities;
- To Workers' Compensation claims or authorities as required by State Workers' Compensation laws;
- To the Plan Sponsor of a Group Health Plan or employee welfare benefit plan (“Plan Sponsor”) for the limited purposes allowed in the law, such as for obtaining premium bids, confirming enrollment of an employee or dependent, and other plan administration functions;
- To law enforcement officials if you are an inmate or under custody. These would be permitted if needed to provide medical services to you or for the protection and safety of others;
- To friends or family members who are assisting you with your health care, with confirmation of that status; and
- To send you communications regarding our fundraising activities. You have the right to choose not to receive such communications.
WHA will not use or disclose your PHI for purposes other than those described in this Notice, unless authorized by you in writing.
Sharing Your PHI with Others
As part of normal business, WHA shares your information with contracted Plan Providers (i.e. medical groups, hospitals, pharmacy benefit management companies, social service providers, etc.) or business associates that perform functions on our behalf. In all cases where your PHI is shared with Plan Providers, Plan Sponsors and business associates, we have a written contract that contains language designed to protect the privacy of your health information. All of these entities are required to keep your health information confidential, and protect the privacy of your information in accordance with State and Federal law.
- for marketing purposes that are unrelated to your benefit plan(s);
- before disclosing any psychotherapy notes;
- before the sale of your health information; and for other reasons as required by law.
If you have given us an authorization, you may revoke it at any time, if we have not already acted on it. You may revoke this authorization as explained in the section titled "Your Rights With Respect to Your PHI."
Your Rights With Respect to Your PHI
You may give us written authorization to use your PHI or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. However, your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
The following are your rights with respect to your health information. If you would like to exercise any of the following rights, please refer to the section below titled, "Questions."
Right to Request Restrictions
You have the right to ask us to restrict how we use and disclose your information for treatment, payment, or health care operations, and for other than treatment, payment, or health care operations, as described in the Notice. You also have the right to ask us to restrict information that we have been asked to give to family members or to others who are involved in your health care. If we agree to your request to restrict health information, we may not use or disclose your PHI for that purpose, except as needed to provide treatment in an emergency. However, we are not required to agree to these restrictions. If we deny your request, we will notify you in writing with the specific reason(s) the request was denied. We also do not have to honor your restriction if we are required by law to disclose the information or when the information is needed for your treatment.
You also have the right to terminate a request for restriction that we have granted. You may do this by calling or writing us. We also have the right to terminate the restriction if you agree to it or if we inform you in writing that we are terminating it. If we do this, it will only apply to medical information that we create or receive after we have informed you.
Your request for a restriction must be in writing and provide us with specific information needed to fulfill your request. This would include the information you wish to be restricted and to whom you want the limits to apply.
Right to Inspect and Copy
You and your personal representative have the right to review or obtain copies of your PHI that may be used to make decisions about you. This includes medical records and billing records. It does not include the following: psychotherapy notes, information to be used in a lawsuit or administrative proceedings, and certain information subject to a law concerning laboratory improvements. Your request must be in writing and provide us with specific information needed to fulfill your request. If you call Member Services at (888) 563-2250 or TTY for the hearing impaired at (888) 877-5378, we will send you a form to request this. Or if you prefer, you may send your written request to our Member Services Department at the address listed in the "Complaints" section of this Notice. If you request copies, we can charge a reasonable fee for the cost of producing the copies and postage. You must pay this fee before we give you the copies. You may also request that we provide you with summary information about your PHI instead of all the information. If so, you must pay us the cost of preparing this summary information before we give it to you.
In certain situations, we may deny your request to inspect or obtain a copy of your PHI. If we deny your request, we will notify you in writing with the specific reason(s) the request was denied. Our letter to you will also include information about how you may request a review of our denial if you are entitled to such a review. Our letter will also tell you about any other rights you have to file a complaint. These are the same rights described in this Notice.
Right to Request an Amendment
You have the right to request that we amend your PHI. Your request must be in writing, and it must explain why the information should be amended. Your request should be sent to our Member Services Department at the address listed in the "Complaints" section of this Notice.
We will deny your request if you fail to submit it in writing or if you fail to include the reasons for your request. We may also deny your request if you ask us to amend information that is (1) accurate and complete; (2) not part of our records; (3) not allowed to be disclosed; or (4) not created by WHA.
If we deny your request, we will provide you a written explanation. This letter will tell you how you can file a complaint with us or with the Secretary of the Department of Health and Human Services. It will also tell you about the right you have to file a statement disagreeing with our denial and other rights you may have.
If we accept your request to amend the information, we will make the changes requested in your amendment. But first we will contact you to identify the persons you want notified and to get your approval for us to do so. We will make reasonable efforts to inform others of the amendment and to include the changes in any future disclosures of that information.
Right to Receive Confidential Communications
You, even if you are a minor, have the right to request that we communicate with you in confidence about your PHI by alternative means or to an alternative location (e.g., mail to a post office box address or fax to a designated number, or by phone at a number you give us). Your request must be made in writing and must clearly state that the medical information involves “sensitive services” as defined in law or that if the request is not granted disclosure could endanger the member. WHA will comply with all requests when required to do so by law; in other cases, WHA will accommodate reasonable requests.
Right to Receive an Accounting of Disclosures
You and your personal representative have the right to receive an accounting of disclosures regarding your health information. Typically the accounting would include disclosures found in the section titled "Other Permitted Uses and Disclosures" of this Notice. The accounting will not cover those disclosures made for the purposes of treatment, payment, and health care operations, and ones that you have authorized. All requests for an accounting must be in writing and include specific information needed to fulfill your request. You can ask for an accounting of times we’ve shared your health information for six (6) years prior to the date you ask. If you request this accounting more than once in a 12-month period, we may charge you a reasonable fee to produce the accounting of disclosures. Before doing so, we will notify you of the fee, and give you an opportunity to withdraw or limit your request in order to reduce the fee.
****** IMPORTANT ******
WHA DOES NOT HAVE COMPLETE COPIES OF YOUR MEDICAL RECORDS. IF YOU WANT TO LOOK AT, GET A COPY OF, OR CHANGE YOUR MEDICAL RECORDS, PLEASE CONTACT YOUR DOCTOR OR MEDICAL GROUP.
Right to Copies of this Notice
You have the right to receive an additional copy of this Notice at any time. You can also find this notice on our website at: westernhealth.com.
How to Complain about Our Privacy Practices
If you believe WHA has violated your privacy rights, or you disagree with a decision we made about access to your health information, you may contact us or the Department of Health and Human Services (DHHS) to make a complaint. We will not retaliate in any way if you choose to file a complaint with us or DHHS. Filing a complaint will not affect your benefits under WHA or Medicare.
Complaints to WHA
If you want to file a complaint with us, you can call or write to:
Complaints to the Federal Government
You also have the right to file a complaint with the federal government. Go to the web address below or call or write to the Office for Civil Rights: www.hhs.gov/ocr/privacy/hipaa/complaints/
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
The terms of this Notice apply to all records containing your health information that are created or retained by WHA. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to the Notice will be effective for all of your records that we have created or maintained in the past. Such revision or amendment shall also be effective for any of your records that we may create or maintain in the future. If we do revise this Notice you will receive a copy and the new notice will be posted on our website at westernhealth.com.
If you have any questions about this notice or want further information, please contact us at:
This Notice is effective August 12, 2016 and remains in effect until changed.
COMP 505 04/2003
Last rev. August 12, 2016
If you, or someone you’re helping, have questions about Western Health Advantage, you have the right to get help and information in your language at no cost. To learn more, please view our Notice of Language Assistance.
Western Health Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. To learn more, please view our Notice of Non-Discrimination.
Last review date: August 12, 2016