Notice of Privacy Practices


PacificSource Community Health Plans

Effective: May 1, 2011

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

PacificSource Community Health Plans (“PacificSource”), is committed to protecting your personal health information. This notice will refer to PacificSource or as “the Plan,” “us,” “we,” or “our.”

Personal Health Information (PHI) is information that is maintained by the Plan that identifies an individual who is applying for, or is enrolled in a plan offered or administered by us. This PHI also relates to information that is created or maintained by the Plan, a person’s participation in the plan, the person’s past, present or future physical or mental health condition, the provision of health care to that person, or payment for the provision of health care to that person. We are required by law to:

  1. Maintain the privacy of your Personal Health Information (PHI);
  2. Provide you with this notice in accordance with the Health Insurance Portability and Accountability Act (HIPAA); and
  3. Follow the policies and procedures set forth in this Notice.

This notice is sent to our existing Plan members and to new members upon enrollment. We reserve the right to change the terms of this Notice at any time. You will be notified of any substantial changes and may request a copy of this notice at any time.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use and disclose your PHI, for payment for your health care, for our health care operations, and for your treatment. Below are examples of the types of uses and disclosures of PHI that we may make without your express authorization.

  1. For Treatment: The Plan may use and disclose PHI to your provider of care (doctors, pharmacies, hospitals and other caregivers) who are treating you. We will disclose PHI when we are helping you obtain services that you may need. This would include services from another agency or caregiver. We may also disclose PHI about health care claims and encounters, medical history, eligibility, payment information and other information for treatment purposes. For example, we may talk to your provider about your condition and disease management or wellness programs to improve the quality of care. We may also use your PHI to review and approve appropriate hospitalization requests.

    The Plan may share your PHI with individuals or entities that perform business functions for us. We may only disclose this information when it is necessary to perform a function and a business relationship exists that would safeguard this information. For example, we may disclose information to a pharmacy benefit management company so that your prescriptions may be filled by a participating pharmacy.

  2. For Payment: The Plan may use and disclose PHI as necessary to determine claims payment for your medical treatment and other care services. This information includes:

    • Eligibility and coverage determinations including coordination of benefits
    • Billing, claims management, obtaining payment under a contract for reinsurance including stop-loss insurance and related health care information

    For example: Your physician or care provider may send a claim for health care services to the Plan for claims adjudication and payment. The claim may contain information that identifies you, your treatment, and your diagnosis.

  3. For Health Care Operations: The Plan may use or disclose PHI in order to support the business activities of the Plan. These activities include such things as:

    • Using PHI to determine if the Plan is meeting certain quality goals and standards
    • Quality assessments and project improvement activities
    • Preventive health, early detection and disease case management programs
    • Training of employees
    • Underwriting and rate setting for certain product lines
    • Sharing PHI for entities that help manage your care
    • Sharing PHI with entities that perform a business function for us. Please note that we will only share this information if there is a business need to do so and if our business associate has signed an agreement to protect your PHI
    • Authorization/Referral process
    • Risk management, auditing and review of systems effectiveness and compliance activities
    • The Plan may use or disclose part of your PHI to offer you additional information regarding the Plan or treatment. For example, we may use your name and address to send a newsletter or other information about activities of the Health Plan
  4. Business associates: Business associates provide necessary services to our organization through contracts. Some examples of business associates are prescription drug benefit administrators, utilization management organizations, and entities that perform quality assurance or peer review on our behalf. We may disclose the minimum necessary medical information to our business associates so they can perform the job we have asked them to do. To protect your medical information, we require our business associates to appropriately safeguard your information. We will not share your information with these outside groups unless there is a business need to do so and they agree to keep it protected. We require our business partners to treat your private information with the same high degree of confidentiality that we do.

  5. Plan administration: We may share enrollment information with your employer to verify your coverage and your family’s coverage for benefits. We may share summary data that cannot be individually identified. We do not share any other information with employers unless we have your written authorization.

  6. Marketing: We will never sell information about you to any third party for marketing or any other purpose not described in this notice. Further, we do not use personal information for investigative consumer research or reporting.

  7. Individuals involved in your care or payment for your care: We may disclose your medical information to a family member, friend, or other person who you indicate is involved in your care or payment for your care. This only pertains to your medical information that is directly relevant to their involvement. We will only make this disclosure if you agree or when required or authorized by law. In the event of your incapacity or in an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest.

  8. As required by law and for law enforcement: We may use or disclose your medical information when required or permitted by federal, state, or local law, or by a court order.

  9. Public health and safety: We may disclose medical information about you to the extent necessary to avert a serious and imminent threat to your health or safety or the health or safety of others.

  10. State and federal agencies: We may be required to report information to state and federal agencies that regulate us, such as the United States Department of Health and Human Services.

  11. Lawsuits and disputes: If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

  12. Military and national security: Under certain circumstances, we may disclose to military authorities the medical information of armed forces personnel. To authorized federal officials, we may disclose medical information required for lawful intelligence, counterintelligence, and other national security activities.

  13. Workers’ compensation: We may disclose medical information to coordinate benefits with workers’ compensation insurance carriers.

  14. Information about health-related benefits: We or our business associates may communicate to you about other services or health-related benefits that may be of interest to you.

  15. Other uses and disclosures: If we use or disclose your information for any reason other than those listed above, we will first obtain your written authorization. State laws may prohibit us from disclosing the following types of sensitive personal information without your authorization: chemical dependency, mental health, psychotherapy, genetic, or HIV/AIDS records. If you give us written authorization, you may revoke it at any time. This will not affect information that has already been shared.

YOUR RIGHTS REGARDING PERSONAL HEALTH INFORMATION (PHI)

The Plan will protect your Personal Health information and ensure that all such disclosures meet the standards listed above. If we use or disclose your information for any other reason the Plan will require your written permission. You must sign a special request and submit it to the Plan for appropriate action. For example, you may provide written permission/authorization for the Plan to release information to a third party such as a caregiver. Remember that once we receive permission to release information, the Plan cannot guarantee that the person receiving the information will not release it elsewhere. Again, the only time we would not need your permission or authorization is if the use or release of this information is permitted or required by state or federal law.

You have certain rights regarding your protected PHI.

  1. You have the right to inspect and copy your PHI. You may inspect and obtain a copy of PHI that is contained in a designated record set for as long as we maintain this information. A designated record set means medical and billing records, and any other records that are used by the Plan. You may be charged a fee for the costs of copying, mailing or other supplies associated with this request. Certain types of PHI will not be made available and includes psychotherapy notes or PHI collected by us in connection with, or in reasonable anticipation of any claim or legal proceedings. Your request must be in writing and the Plan will respond to your request no later than 30 days after we receive the request. If for any reason this information is not available on-site, we will respond within 60 days.

  2. You have the right to request that the Plan change or amend your PHI. You may request that the Plan change information that is contained in a designated record set. The Plan has the option to agree to the request. You must make this request in writing and the Plan will inform you of the action it will take. If we deny your request you have the right to file a written disagreement with the Plan decision that will be included with any further disclosures of that information. The Plan may deny the request if the information you propose to include or replace existing information is:

    1. Not accurate or complete;
    2. Was not created by the Plan;
    3. May be evidence of a crime; or
    4. Where it is otherwise necessary for the Plan to comply with state and federal regulations.

  3. You have the right to a list of disclosures the Plan has made of your PHI. This listing will not include disclosures that were made for treatment, payment, health care operations, or required by law as listed above. This list of disclosures will not include any information prior to April 14, 2003. Your request should be in writing and include the specific time frame that you are interested in.

  4. You have the right to place a restriction or limitation on PHI that the Plan may use or disclose about you for treatment, payment or health care operations. The Plan may consider your request but is not required to agree to it. To request a restriction, you must make your request in writing and tell us what information you want to limit and the time frame involved. If the Plan does not agree to these restrictions you will be sent a written notification. Please be aware that the Plan cannot agree to restrict the use and disclosure of PHI that the Plan is legally required to do, or that is necessary for treatment, payment, or health care operations.

  5. You have the right to request that the Plan communicate with you in a certain way or at a certain location. For example, you can ask that we only contact you by telephone or by mail. To request this confidential communication arrangement, you must make your request in writing. The Plan will consider and accommodate all reasonable requests.

  6. You have the right to request a copy of this notice from us at any time.

EXERCISING YOUR RIGHTS AND FILING OF COMPLAINTS

If you believe your privacy rights have been violated you may file a written complaint with the Plan Privacy Contact. Please be assured that the Plan will not retaliate against you for filing a complaint. You may contact:

  • PacificSource Community Health Plans
  • Attn: Grievance/Appeals Administrator
  • 2965 NE Conners Avenue
  • Bend, OR 97701

You may also notify the U.S Department of Health and Human Services

  • U.S. Department of Health and Human Services
  • 200 Independence Ave SW
  • Room 509F, HHH Building
  • Washington DC 20201

If you have any questions please contact the Customer Service Department at (541) 385-5315 or toll free at (888) 863-3637 (TTY 1-800-735-2900).

CHANGES TO THIS NOTICE OF PRIVACY PRACTICES

This Notice takes effect on May 1, 2011. It will remain in full force and effect until we update or replace it. If you are a member, you will be mailed a copy of any significant changes to these Privacy Practices at least 60 days prior to the implementation of the same. You may request a copy of this Notice be mailed to you at any time.