2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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13. Health Insurance PortabilityQuality Improvement Program13. Health Insurance Portability and Accountability Actand Accountability ActThis chapter provides a high-level overview of thefollowing critical federal regulations created toaddress key concerns relating to electronic healthinformation:The Health Insurance Portability and AccountabilityAct (HIPAA) of 1996The Health Information Technology for Economicand Clinical Health (HITECH) Act of 2009The HIPAA Final Omnibus Rule of 2013HIPAA regulations are detailed in the Code ofFederal Regulations (CFR) Title 45, whichaddresses public welfare and is administered bythe U.S. Department of Health and HumanServices (DHHS). The specific regulations thataddress HIPAA are 45 CFR Parts 160 and 164,which can be reviewed in their entirety athttp://www.ecfr.gov/cgi-bin/textidx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl.This chapter’s overview includes a brief descriptionof the relevance of these regulations to allproviders, and a list of informational and trainingresources for providers seeking additionalinformation.What Requires Your Particular Attention?Providers are advised to pay particular attention tothe recently enacted (September 23, 2013) HIPAAFinal Omnibus Rule.You can review the Federal Register release of this25/pdf/2013-01073.pdf.The American Medical Association provides anumber of resources for physicians atrule at http://www.gpo.gov/fdsys/pkg/FR-2013-01-http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act.page.These resources include a .pdf titled “HIPAAPrivacy and Security Toolkit: Helping Your PracticeMeet New Compliance Requirements.”Many additional resources posted online by DHHS,trade associations, and commercial entities areavailable to providers seeking to ensure that theyare fully compliant.Who is Legally Responsible for HIPAACompliance?All providers are solely responsible for theircompliance with HIPAA regulations. Presbyteriandoes not assume any responsibility for ensuringthat providers are compliant.The information provided in this chapter should notbe construed as legal advice; providers shouldconsult their own legal counsel for an opinion as tohow these regulations apply to their office or facility.13-12014 Practitioner and Provider Manual - Ver. 3
Health Insurance Portability and Accountability ActWhich Providers Must Be HIPAA Compliant?All providers who handle members’ protectedhealth information (PHI) for treatment purposes arelegally obliged to observe HIPAA regulations.Those providers who perform a service on behalf ofPresbyterian for non-treatment purposes are alsolegally obliged to observe HIPAA regulations. Sucha service might include any function or activityspecified in the definition of business associate in45 CFR §160.103. These activities performedinclude:Claims processing or administrationData analysis, processing, or administrationUtilization reviewQuality assurancePatient safety activitiesBilling, benefit management, practice management,and/or repricingAdditional services such as legal, actuarial,accounting, consulting, data aggregation,management administration, accreditation, orfinancial where the provision of services involvesthe disclosure of PHIKey HIPAA DefinitionsThe three definitions in this section are derivedfrom 45 CFR 160.103. HIPAA definitions can alsobe found in 45 CFR 160.202, 160.401, 160.502,164.103, 164.304, 164.402, and 164.501. (Seehttp://www.ecfr.gov/cgi-bin/textidx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl.)Covered entity meansA health planA health care clearinghouseA health care provider who transmits any healthinformation in electronic form in connection with atransaction covered by 45 CFR 160Protected Health Information (PHI) meansindividually identifiable health information that iscreated or received by a health care provider,health plan, or health care clearinghouse relating tothe past, present, or future physical or mentalhealth or condition of an individual or payment forhealth care and is transmitted by electronic media,maintained in electronic media, or transmitted ormaintained in any other form or medium, excludingeducation records or employment records held by acovered entity in its role as employer.Business associate means a person who is not amember of the workforce that creates, receives,maintains, or transmits PHI for a function or activityinvolving the use or disclosure of PHI on behalf of acovered entity. See Appendix E in this manual for acopy of the Business Associate Agreement.HIPAAHIPAA contains several key components:Title I protects a workers’ health insurancecoverage when they lose or change jobsTitle II, which is also known as the AdministrativeSimplification Regulation, mandates that the DHHScreate national regulations to address several keyconcerns relating to the privacy and security ofpatient health information including13-22014 Practitioner and Provider Manual - Ver. 3
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Appendix A. Acronyms ..............
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1. Presbyterian Healthcare Services
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Presbyterian Healthcare Services(HS
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Presbyterian Healthcare ServicesReg
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Presbyterian Healthcare Services2.
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Provider Network Managementthis man
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Centennial Care Overview3. Primary
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Primary Care ProvidersClaims Activi
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Primary Care Providers4. Specialist
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SpecialistsOther Information for PC
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Specialists5. Preventive Health Car
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Preventive Health Care GuidelinesPr
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Preventive Health Care GuidelinesSe
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Care Coordination6. Care Coordinati
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Care CoordinationPresbyterian’s c
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Care Coordinationthe program. If th
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Care Coordinationdesignated family
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Care CoordinationFacilitate access
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Care CoordinationClinical Practice
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Care Coordinationformula, which is
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Care CoordinationAmerican Psychiatr
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Care Coordinationwithout obtaining
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Care CoordinationSpecialists as PCP
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Care Coordinationor when the member
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Care Coordination11. Prevention Scr
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Care CoordinationFollow-up plans or
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Care CoordinationPharmacy BenefitsP
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Care CoordinationThis page intentio
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Laboratory ServicesTriCore Contact
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Pharmacya multi-tier formulary stru
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Pharmacymedications. This multi-tie
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PharmacyCatastrophic coverage: Cove
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Pharmacywhich drugs are mandated th
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PharmacyThe drug must be accepted f
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PharmacyTypes of Pharmacy Prior Aut
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PharmacyThis page intentionally lef
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Behavioral Healthagreements, addend
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Page 107 and 108: Long-Term Carean individual provide
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Page 133 and 134: Quality Improvement ProgramNational
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Page 165 and 166: Legal15. Fraud, Waste, and Abuse15.
Page 167 and 168: Fraud, Waste, and Abuseas the time
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Page 187 and 188: e-BusinessFill out the form on the
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Page 193 and 194: e-Business18. Claims and Payment18.
Page 195 and 196: Claims and Paymentsubmission. Claim
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Claims and PaymentSpecify the origi
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Claims and Paymentrequiring a leadi
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Claims and PaymentPlease note that
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Claims and PaymentPresbyterian is r
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Claims and Paymentnot made a recove
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Claims and PaymentAcceptable docume
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Claims and Paymentallowing provider
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Claims and PaymentNational Correct
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Claims and Payment19. Presbyterian
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Presbyterian Customer Service Cente
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Appeals and Grievances20. Appeals a
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Appeals and GrievancesMember Appeal
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Appendix A. AcronymsAppendix A. Acr
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Appendix A. AcronymsHMOHRAHSDHealth
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Appendix A. AcronymsWWEDIWorkgroup
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Appendix B: DefinitionsAppendix B.
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Appendix C. WebsitesAppendix C. Web
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Appendix C. WebsitesWebsitesNameCul
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Appendix C. WebsitesWebsitesNameMem
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Appendix C. WebsitesWebsitesNameWED
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Appendix C. WebsitesAppendix D. Pho
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Appendix D. Phone NumbersPhone Numb
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Appendix B: Business Associate Agre
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Appendix E. Business Associate Agre
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Appendix F. Prior Authorization Gui
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Appendix G. Alternative BenefitsG.
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Appendix G. Alternative Benefits Pa
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