5.3. ERMUSR 02-09-2010 - Laserfiche WebLink

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ARTICLE XIII HIPAA PROVISIONS The Privacy Rules and Security Rules under HIPAA apply to certain Optional Benefits of the Plan that constitute "covered entities" within the meaning of HIPAA (e.g., employer sponsored group health plans), 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. 13.1 Use and Disclosure of PHI. The plan will use PHI to the extent of 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. (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; (11) utilization review, including pre-certification, preauthorization, concurrent review and retrospective review; (12) disclosure to consumer reporting agencies related to the collection of premiums or reimbursement (the following PHI may be disclosed for - payment purposes: name and address, date of birth, Social Security 39