4.13 SR 05-06-2024 - Laserfiche WebLink

Home Browse Search

© 2012 Hitesman & Wold, P.A. City of Elk River Flexible Benefits Plan 45 ARTICLE XIX. HIPAA PROVISIONS The Privacy Rules and Security Rules under HIPAA apply to the Medical Expense Reimbursement Plan and the Limited Scope Medical Expense Reimbursement Plan unless such Optional Benefits are self- insured and have less than fifty (50) Participants and the Employer is the Claims Administrator for such Optional Benefits for the purposes of this Article XIX, such Optional Benefits are referred to as the “Plan.” 19.1 Use and Disclosure of PHI. The Plan will use PHI to the extent allowed by, and in accordance with the uses and disclosures permitted by, HIPAA. Specifically, the plan will use and disclose PHI for purposes related to health care treatment, payment for health care and health care operations. The Plan will also use and disclose PHI as required by law and as permitted by authorization of the subject of PHI. If the Plan discloses PHI to the Employer in accordance with this Article XIX, the Employer may use and further disclosure PHI for the same purposes and in the same situations as the Plan may use and disclose PHI, provided that such use or disclosure is for Plan administration functions performed by the Employer for the Plan or is required by law or permitted by authorization. All uses and disclosures of PHI, whether by the Plan or by Employer, shall be limited to the minimum PHI necessary to accomplish the intended purpose of the use or disclosure in accordance with HIPAA. Notwithstanding the foregoing, neither the Plan nor the Employer shall use PHI that is genetic information in a manner that is prohibited by the Genetic Information Nondiscrimination Act of 2008. (a) Payment includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of Plan benefits that relate to an individual to whom health care is provided. These activities include, but are not limited to, the following: (1) determination of eligibility, coverage and cost sharing amounts (for example, cost of a benefit, Plan maximums and co-payments as determined for an individual’s claim); (2) coordination of benefits; (3) adjudication of health benefits claims (including appeals and other payment disputes); (4) subrogation of health benefit claims; (5) establishing employee contributions; (6) risk adjusting amounts due based on enrollee health status and demographic characteristics; (7) billing, collection activities, and related health care data processing; (8) claims management and related health care data processing, including auditing payments, investigating and resolving payment disputes and responding to participant inquiries about payments; (9) obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance); (10) medical necessity reviews or reviews of appropriateness of care or justification of charges; Page 138 of 254