5.3. ERMUSR 02-09-2010 - Laserfiche WebLink

Home Browse Search

number, payment history, account number and name and address of provider and/or health plan); and (b) (13) reimbursement to the plan. Health care operations include, but are not limited to, the following activities: (1) quality assessment; (2) population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, disease management, contacting health care providers and patients with information about treatment alternatives and related functions; (3) rating provider and plan performance, including accreditation, certification, licensing or credentialing activities; (4) underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relating to health care claims (including stop-loss insurance and excess of loss insurance); (5) conducting or arranging for medical review, legal seMces and auditing function, including fraud and abuse detection and compliance programs; (6) business planning and development, such as conducting cost- management and planning-related analyses related to managing and operating the plan, including formulary development and administration, development or improvement of payment methods or coverage policies; (7) business management and general administration activities of the plan, including, but not limited to: i) management activities relating to the implementation of and compliance with HIPAA's administrative simplification requirements; 13.2 ii) customer service, including data analyses for policyholders. (8) resolution of internal grievances; and (9) due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the potential successor in interest is a covered entity under HIPAA or following completion of the sale or transfer, will become a covered entity. Employer's Obligations under the Privacy Rules. Under the Privacy Rules, the plan may not disclose PHI to the Employer unless the Employer agrees to certain 40