I'm not sure I entirely understand what you are looking for here, but in the case of
EOBs and Privacy...
Privacy should not effect your EOB process as a whole. I have cut out two sections in
the Privacy Rules where HHS has responded in the Final Rule that the generation of the
EOB containing information other than the policy holder is permitted since it is
considered a payment operation. Therefore, the way you send your EOBs and checks
today will not necessarily have to change. You will have to allow for a "Confidential
Communication" method - if an individual reasonably requests that their information be
sent to another address because it could potentially cause them harm - but I don't see
this being the norm.
Privacy Final Rules, page 82607, column 3
Comment: A commenter noted that the definition of ''disclosure'' should
reflect that health plan correspondence containing protected health information, such
as Explanation of Benefits (EOBs), is frequently sent to the policyholder. Therefore,
it was suggested that the words ''provision of access to'' be deleted from the
definition and that ''disclosure'' be clarified to include conveyance of protected
health information to a third party.
Response: The definition is, on its face, broad enough to cover the transfers of
information described and so is not changed. We agree that health plans must be able
to send EOBs to policyholders. Sending EOB
correspondence to a policyholder by covered entity is a disclosure for
purposes of this rule, but it is a disclosure for purposes of payment.
Therefore, subject to the provisions � 164.522(b) regarding Confidential
Communications, it is permitted even it discloses to the policyholder
protected health information about another individual (see below).
Privacy Final Rule, page 82615, column 2
Comment: Certain commenters explained that third party administrators usually
communicate with employees through Explanation of Benefit (EOB) reports on behalf of
their dependents (including those who might not be minor children). Thus, the employee
might be apprised of the medical encounters of his or her dependents but not of
medical diagnoses unless there is an over-riding reason, such as a child suspected of
drug abuse due to multiple prescriptions. The commenters urged that the current claim
processing procedures be allowed to continue.
Response: We agree. We interpret the definition of payment and, in particular the term
''claims management,'' to include such disclosures of protected health information.
>>> "Ken Hoover" <[EMAIL PROTECTED]> 8/3/01 11:02:51 AM >>>
Scenario:
Participant (employee) has an adult dependent (spouse, child 18 or over,
etc).
The dependent receives services from a provider to whom should the payer
send the explanation of benefits (EOB) to (Participant or Dependent)? What
if there is a reimbursement due to participant/dependent? Who gets the
check?
Thanks,
Ken Hoover
Acclamation Systems, Inc
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