ADVANTAGE Health Solutions, Inc.SM
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal
law that requires ADVANTAGE Health Solutions, Inc.SM (ADVANTAGE) to inform you of
your right, our legal duties and our privacy practices. By enrolling in this Plan,
you understand that ADVANTAGE has the right to utilize your personal medical information
for future, known or routine needs for the purposes of treatment, payment, and health
care operations.
We must follow the privacy practices that are described in this notice while it
is in effect. This notice takes effect Nov 30, 2009, and will remain in effect until
we replace it. In this notice, “we”, “us” and “our(s)” refers to ADVANTAGE and all
its commercial products and lines of services.
Your consent to this Notice is a condition of your enrollment in ADVANTAGE. You
have the right to revoke this consent in writing at any time.
ADVANTAGE Health Solutions, Inc.’sSM LEGAL DUTY
ADVANTAGE is required by applicable federal and state laws to keep information about
you private. Private information is information that we obtain to provide you with
coverage and that identifies you as an individual, such as name, social security
number, and other information about you that is non public and that relates to your
medical history. ADVANTAGE refers to this information as “health information.” The
terms used in this Notice of Privacy Practices should be consistent with the HIPAA
Privacy Regulations. Any terms not defined in this Notice will have the same meaning
as they have in the HIPAA Privacy Regulation.
ADVANTAGE reserves the right to change our privacy practices and the terms of this
notice at any time, provided that such changes are permitted by applicable law.
We reserve the right to make the new changes and terms of our privacy practices
effective for all health information that we maintain, including health information
ADVANTAGE created or received before we made the changes. Before we make significant
change in our privacy practices, ADVANTAGE will change this notice and provide you
with the revised notice by one of the following means: by mail or posting on the
ADVANTAGE website within 60 days of their effective date.
You may request a copy of our notice at any time. If you’d like to request a copy
or obtain additional information, please contact us using the contact information
listed at the end of this notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
ADVANTAGE may use and disclose your health information without your authorization
for the purposes of treatment, payment, and health care operations. The sections
below describe the ways ADVANTAGE uses and releases your health information for
these purposes. Your health information is not shared with anyone who does not have
a “need to know” to perform one of the tasks listed below.
Treatment: ADVANTAGE may use your health information or disclose it to third
parties to coordinate and oversee your medical care. For example, we may use your
health information to help you find a doctor or a hospital that can treat your specific
health needs.
Payment: ADVANTAGE may use and disclose your health information for purposes
of payment, including, but not limited to, billing, collecting payment for health
care treatment, verifying eligibility for plan benefits, determining plan responsibility
for benefits, and coordinating benefits. For example, we may use your health information
when we receive a claim for payment. We may also disclose this information to another
insurer if you are covered under more than one plan.
Health Care Operations: ADVANTAGE may use your health information and disclose
it to third parties in order to assist in ADVANTAGE’s everyday work activities such
as looking at the quality of your care, carrying out utilization review, disease
management and wellness purposes and ADVANTAGE’s business planning. For example,
your health information may be released to members of ADVANTAGE staff to review
the quality of care and outcomes. Your health information may be released to doctors
or doctor groups involved in your care to improve patient care. Additionally, ADVANTAGE
may also use your health information to give you information about one of our disease
management and wellness programs, treatment alternatives, and other health-related
services available to you. In using and disclosing your health information for payment
and health care operations, we may only request, use and disclose the minimum amount
of health information necessary to complete any task.
Disclosures to Other Covered Entities: ADVANTAGE may disclose personal health
information to other covered entities, or business associates of those entities
for treatment, payment and health care operation purposes. For example, we may disclose
health information to other health plans if needed to have certain expenses reimbursed
as part of the coordination of benefits.
Underwriting: ADVANTAGE may receive your health information for underwriting,
premium rating or other activities relating to the creation, renewal or replacement
of a contract of health insurance or health benefits. We will not use or further
disclose this health information for any other purpose, except as required by law,
unless the contract of health insurance or health benefits is placed with us. In
that case, our use and disclosure of your health information will only be as described
in this notice.
• The Genetic Information Non-discrimination Act of 2009 (GINA)
specifically prohibits us from using, disclosing or requesting health information
that is genetic information about you, as defined under GINA, for underwriting purposes.
Genetic information about you is defined as (1) your genetic tests; (2) genetic
tests of your family member; (3) family medical history, or (4) any request of or
receipt by you or your family members of genetic services. This means that we are
prohibited from using your genetic information for enrollment, continued eligibility,
computation of premiums, or other activities related to underwriting. A written
authorization cannot be used to permit a use or disclosure of this kind.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES PERMITTED
WITHOUT YOUR AUTHORIZATION OR OPPROTUNITY TO AGREE OR OBJECT
ADVANTAGE may use or disclose your protected health information in the following
situations without your authorization or providing you the opportunity to agree
or object. These situations include:
• Plan Administration: to your employer, when we receive
a certification from the plan sponsor (employer group), that informs us that appropriate
language has been included in the plan documents allowing for the disclosure of
your health information or when summary health information is disclosed to assist
your employer with plan administration on behalf of the group health plan. “Summary
Health Information” is information that summarizes the claims, history, claims expenses
or types of claims experienced by you and other members of your group health plan,
from which specific identifiers have been deleted.
• Business Associates: to third parties to assist us with
activities that allow us to provide you with coverage and that involve the use of
your health information. We refer to those third parties as our Business Associates.
We enter into written agreements with our Business Associate and require them to
abide by the same rules, regulations and practices we do to protect your health
information.
• Industry Regulation: to the U.S. Department of Health
and Human Services, state insurance department, and other government agencies that
regulate us. We may also disclose your health information when authorized by workers’
compensation or similar laws.
• Law Enforcement: limited information to federal, state
and local law enforcement officials concerning the health information of a suspect,
fugitive, material witness, crime victim or missing person.
• Legal Process and Proceedings: in response to a court
or administrative order, subpoena, discovery request, or other lawful process, under
certain circumstances. Under limited circumstances, such as a court order, warrant,
or grand jury subpoena, we may disclose your health information to law enforcement
officials.
• Public Health and Safety: to the extent necessary to avert
a serious and imminent threat to your health or safety or the health or safety of
others. We may disclose your health information to address public interest concerns
as required or permitted by law. For example, if we believe you are a possible victim
of abuse, neglect, domestic violence or other crimes.
• Military and National Security: the health information
of Armed Forces personnel to authorized Military authority personnel under certain
circumstances for lawful intelligence, counterintelligence, and other national security
activities.
• Emergency: when the situation, such as medical emergency
or disaster relief, indicates that disclosure would be in your best interest, AVANTAGE
may disclose your health information to a family member, friend or other person
to the extent necessary to help with your health care or with payment for your health
care services.
• Research; Death; Organ Donation: for research purposes
in limited circumstances, to a coroner, medical examiner, funeral director, or organ
procurement organization for certain purposes.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT REQUIRE PROVIDING YOU THE
OPPORTUNITY TO AGREE OR OBJECT
ADVANTAGE may use and disclose your protected health information in the following
instances. You have the opportunity to agree or object to the use or disclosure
of all or part of your protected health information. If you are not present or able
to agree or object to the use or disclosure of the protected health information,
then ADVANTAGE, using professional judgment, may determine whether the disclosure
is in your best interest.
Others Involved in Your Healthcare or Payment for Your Care: We may disclose
to a member of your family, a relative, a close friend, or any other person you
identify, your protected health information that directly relates to that person’s
involvement in your health care. For example, if a family member contacts us with
prior knowledge of a claim, we may confirm whether or not the claim has been received
and paid. If you do not want your protected health information to be shared this
way, please contact us using the contact information listed at the end of this notice.
If you are unable to agree or object to such a disclosure, ADVANTAGE may disclose
such information as necessary if ADVANTAGE determines that it is in your best interest
based on its professional judgment. ADVANTAGE may also use or disclose protected
health information to notify or assist in notifying a family member, personal representative,
or any other person that is responsible for your care of your location, general
condition, or death. Finally, ADVANTAGE may use or disclose your protected health
information to an authorized public or private entity to assist in disaster relief
and to coordinate uses and disclosures to family or other individuals involved in
your health care. You have the right to stop or limit this kind of disclosure by
contacting us using the information listed at the end of this notice.
Marketing: ADVANTAGE may use your health information to contact you with
information about health-related benefits and services, including but not limited
to, ADVANTAGE’s disease management programs and quality improvement activities that
may be of interest to you. We may disclose your health information to a business
associate to assist us in these activities. Unless the information is provided to
you by a general newsletter or in person, you may opt-out of receiving further such
information by contacting us using the contact information listed at the end of
this notice.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
BASED UPON YOUR WRITTEN AUTHORIZATION
In all situations other than those described above, we will ask for your written
authorization before using or disclosing your health information. An authorization
is also needed for certain releases of health information dealing with mental health
issues, substance abuse issues, HIV/AIDS and grievances You may revoke your authorization,
in writing, at any time. Once revoked, we will no longer use or release health information
about you for the reasons covered by your written authorization. We are unable to
take back any disclosures we have acted on based on your authorization.
Personal Representatives: We will disclose your health information to an
individual who has been designated by you as your personal representative and who
has qualified for such designation in accordance with relevant law. You must provide
us with written documentation that supports and established the basis for the personal
representation. We may elect not to treat the person as your personal representative
if we have a reasonable belief that you have been, or may be, subjected to domestic
violence, abuse, or neglect by such person or is not in your best interest. We can
provide you with a Sample Authorization Form.
INDIVIDUAL RIGHTS
Access: We are required to disclose to you your health information when you
request access to this information. You have the right to view or obtain copies
of your health information, with limited exceptions. If you would like copies of
your health information, or would like your information in a special format (i.e.
electronic or media), we may charge you a fee. You have a right to choose what portion
of your PHI you want copied and to have prior notice of copying costs. If for some
reason we deny your request for access to your health information, we will provide
a written explanation of why your request was denied and explain how you can appeal
the denial. You may request that ADVANTAGE provide copies in a format other than
photocopies (i.e. electronic). We will use the format you request unless we cannot
practicably do so.
Disclosure Accounting: You have the right to receive a list of instances
in which ADVANTAGE or our business associates disclosed your health information
obtained or created since April 14, 2003 for purposes other than treatment, payment
or health care operations and certain other authorizations. We will provide you
with the date(s) on which we made the disclosure, the name(s) of the person or entity(ies)
to whom we disclosed your health information, a description of the health information
disclosed, and certain other information. If you request this list more than once
in 12-month period, we may charge you a reasonable, cost-based fee for responding
to these additional requests. Contact us using the information listed at the end
of this notice for a full explanation of our fee structure.
Restriction Request: You have the right to request that ADVANTAGE place additional
restrictions on our use or disclosure of your health information. We are not required
to agree to these additional restrictions, but if we do, we will abide by our agreement
(except in an emergency or as otherwise required by law). Any agreement ADVANTAGE
may make to a request for additional restrictions must be in writing and signed
by a person authorized to make such an agreement on your behalf. ADVANTAGE will
not be bound unless our agreement is so memorialized in writing.
Confidential Communication: You have the right to request that ADVANTAGE
communicate with you in confidence about your health information by alternative
means or to an alternative location. You must inform us that confidential communication
by alternative means or to an alternative location is required to avoid endangering
you. You must make your request in writing, and you must state that the information
could endanger you if it is not communicated in confidence by the alternative means
or to the alternative location you want. ADVANTAGE must accommodate your request
if it is reasonable, specifies the alternative means or location, and continues
to permit us to collect premiums and pay claims under your health plan.
Amendment: You have the right to request that ADVANTAGE amend your health
information. Your request must be in writing, and it must explain why the information
should be amended. ADVANTAGE may deny your request if we did not create the information
you want amended or for certain other reasons. If we deny your request, we will
provide you a written explanation. You may respond with a statement of disagreement
to be appended to the information you wanted amended. If we accept your request
to amend the information, we will make reasonable efforts to inform others, including
people you name, of the amendment and to include the changes in any future disclosures
of that information.
Electronic Notice: If you receive this notice on our web site (www.advantageplan.com) or by electronic e-mail, you are
entitled to receive this notice in written form. Please contact us using the information
listed at the end of this notice to obtain this notice in written form.
QUESTIONS AND COMPLAINTS
If you are concerned that we may have:
• Violated your privacy rights;
• You disagree with a decision we made about access to your health
information;
• In response to a request you made to amend or restrict the use
or disclosure of your health information; and/or
• In response to a request you made to have us communicate with
you in confidence by an alternative means or at an alternative location
You may complain to ADVANTAGE using the contact information listed at the end of
this notice. You also may submit a written complaint to the U.S. Department of Health
and Human Services. We will provide you with the address to file your complaint
with the U.S. Department of Health and Human Services upon request.
ADVANTAGE supports your right to protect the privacy of your health information.
We will not retaliate in any way if you choose to file a complaint with us or the
U.S. Department of Health and Human Services. If you want more information about
our privacy practices or have questions or concerns, please contact us using the
information listed at the end of this notice.
LANGUAGE ASSISTANCE
ADVANTAGE contracts with Language Line Services to assist non-English speaking members
in accessing ADVANTAGE resources and getting answers to questions. The interpreters
may communicate directly with the member and ADVANTAGE representatives to resolve
member questions. The communication may include information related to your health
care. You may request this service by contacting us using the information listed
below.
CONTACT INFORMATION
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