Cooperative Extension Service
Departments
Human Resources - Benefits
Notice of Privacy Practices
This Notice Describes How Medical Information About You May Be
Used And Disclosed And How You Can Get Access To This Information.
Please Review It Carefully.
This notice of Privacy Practices describes how the University of Arkansas
Health and Dental Plans may collect, use and disclose your protected health
information, and your rights concerning your protected health information.
“Protected health information” (PHI) is information about you, including
demographic information collected from you, that can reasonably be used to
identify you and that relates to your past, present or future physical or mental
health or condition, the provision of health care to you or the payment for that
care.
We are required to maintain the privacy of your protected health information
and to provide you this notice about our legal duties and privacy practices. We
must follow the privacy practices described in this notice while it is in
effect. This notice takes effect April 14, 2003, and will remain in effect until
replaced, modified, or amended.
Uses And Disclosures Of Protected Health Information
Uses and Disclosures for Payment and Health Care Operations. The
University of Arkansas Health and Dental Plans do not disclose Protected Health
Information unless required by law. However, we do use Protected Health
Information for payment and for health care operations.
Payment: We will use your protected health information to administer
your health benefits policy or contract, which may involve the determination of
eligibility; claims payment; utilization review and care management; medical
necessity review; coordination of care, benefits and other services; and
responding to complaints, appeals and external review requests. We may also use
protected health information for purposes of premium billing, and the
determination of premium rates and co-payments, deductibles, co-insurance and
other cost sharing amounts.
Health Care Operations: We will use your protected health information
to support other business activities, including the following:
Health claims analysis.
Premium determination and administration of reinsurance.
Risk management.
Transfer of eligibility and plan information to business associates (for
example, Pharmacy Benefit Management -PBM’s- for the management of pharmacy
benefits).
Other general administrative activities, including data and information
systems management and customer service.
We will not disclose protected health information to any University of
Arkansas employee unless required by law. We will, however, provide minimal
protected information necessary to allow payroll to pay the monthly premium for
your group health enrollment (for example, name, identification number, and
family coverage status).
Other Permitted or Required Uses and Disclosures of Protected Health
Information.
The University of Arkansas Health and Dental Plans will not disclose
Protected Health Information unless required by law. We may disclose your
protected health information in the following additional situations without your
authorization:
Others Involved in Your Healthcare: Unless you request Restriction or
Confidential Communication, we may disclose to your spouse (or your parent
if you are a dependent child), the Protected Health Information directly related
to payment for health care services. Otherwise, we will not disclose your
Protected Health Information regarding health care to your spouse, your family
(except for parents of dependents covered under the plan), a relative, a close
friend, or any other person without your signed authorization explicitly
directing us to do so. If you are present for such a disclosure (whether in
person or on a telephone call), we will either seek your verbal agreement to the
disclosure or provide you an opportunity to object to it. We may also make such
disclosures to the persons described above in situations where you are not
present or you are unable to agree or object to the disclosure, if we determine
that the disclosure is in your best interest. We may also disclose your
protected health information to an authorized public or private entity to assist
in disaster relief efforts.
Unless our administrator (QualChoice/QCA or Delta Dental) is given an
alternative address, your explanation of benefits forms and other mailings
containing protected health information will be sent to the address on record
for the subscriber of the health benefits plan. Separate mailings for enrolled
dependents of the subscriber will not be done, unless requested through the
administrator by Confidential Communications described in this notice. If
available, this also pertains to the claims information contained electronically
and available via secured Internet access and corresponding telephonic claims
sites.
If you would not like us to share any information in any of the foregoing
manners with any particular individuals or organizations, please call the
appropriate number listed on page 4 of this document.
Required By Law
We may use or disclose your protected health information to the extent we are
required to do so by law.
Public Health: We may disclose your protected health information to
an authorized public health authority for purposes of public health activities.
The information may be disclosed for such reasons as controlling disease, injury
or disability. In addition, we may make disclosures to a person or company
required by the Food and Drug Administration to report adverse events, product
defects or problems, track products; to enable product recalls; to make repairs
or replacements, or to conduct post marketing surveillance, as required.
Abuse or Neglect: We may make disclosures to government authorities
concerning abuse, neglect or domestic violence.
Health Oversight: We may disclose your protected health information
to a government agency authorized to oversee the healthcare system or government
programs, or its contractors (e.g., state insurance department, U.S. Department
of Labor) for activities authorized by law, such as audits, examinations,
investigations, inspections and licensure activity.
Legal Proceedings: We may disclose your protected health information
in the course of any legal proceeding, in response to an order of a court or
administrative tribunal and, in certain cases, in response to a subpoena,
discovery request or other lawful process.
Law Enforcement: We may disclose your protected health information
under limited circumstances to law enforcement officials. For example,
disclosures may be made in response to a warrant or subpoena or for the purpose
of identifying or locating a suspect, witness or missing persons or to provide
information concerning victims of crimes.
Coroners, Funeral Directors and Organ Donation: We may disclose your
protected health information in certain instances to coroners, funeral directors
and in connection with organ donation.
Research: We may disclose your protected health information to
researchers, provided that certain established measures are taken to protect
your privacy.
Threat to Health or Safety: We may disclose your protected health
information to the extent necessary to avert a serious and imminent threat to
your health or safety or to the health or safety of others.
Military Activity and National Security: We may disclose your
protected health information to Armed Forces personnel under certain
circumstances and to authorized federal officials for the conduct of national
security and intelligence activities.
Correctional Institutions: If you are an inmate in a correctional
facility, we may disclose your protected health information to the correctional
facility for certain purposes, including the provision of health care to you or
the health and safety of you or others.
Workers’ Compensation: We may disclose your protected health
information to the extent required by workers’ compensation laws.
Uses and Disclosures of Protected Health Information with an Authorization.
Other uses and disclosures of protected health information will be made only
with your written authorization, unless otherwise permitted or required by law.
You may revoke this authorization, at any time, in writing, except to the extent
that we have taken an action in reliance on the use or disclosure indicated in
the authorization being revoked.
Many members ask us to disclose their protected health information to third
parties for reasons not described in this notice. For example, elderly members
often ask us to make their records available to caregivers. The administrator of
the group Health and Dental Plans maintains this information. To authorize us to
disclose any of your protected health information to a person or organization
for reasons other than those described in this notice, please call the
appropriate number listed on page 4 of this document and you will be provided
the appropriate authorization and address to submit the form. You may revoke the
authorization at any time by sending a letter to the same address. Please
include your name, address, member identification number and a telephone number
where we can reach you.
Member Rights
The following is a brief statement of your additional rights with respect to
your protected health information:
Right to Request Restrictions: You have the right to ask us to place
restrictions on the way we use or disclose your protected health information for
treatment, payment or healthcare operations or as described in the section of
this notice entitled “Others Involved in Your Healthcare.” However, we
are not required to agree to these restrictions. If we do agree to a
restriction, we may not use or disclose your protected health information in
violation of that restriction, unless it is needed for an emergency. All
requests for restrictions should be submitted to the administrator of our group
Health and/or Dental Plans.
Confidential Communications: We will accommodate reasonable requests
to communicate with you about your protected health information by alternative
means or to alternative locations. For example, if you are covered under a
Health and/or Dental Plan as an adult dependent (e.g., a spouse or a child
attending college) and you want us to send correspondence that contains
protected health information to a different address from the subscriber we can
accommodate that request. We may ask you to make your confidential communication
request in writing. All requests for confidential communications should be
submitted to the administrator of our group Health and/or Dental Plans.
Access to Protected Health Information: You have the right to receive
a copy of protected health information about you that is contained in a
“designated record set”, with some specified exceptions. A “designated record
set” means a group of records that are used by or for us to make decisions about
you, including enrollment, payment, claims adjudication and case or medical
management records. Any request to access protected health information should be
directed to the administrator of our group Health and/or Dental Plans.
You may be asked to request access to copies of your records in writing and
to provide the specific information needed to fulfill your request. We reserve
the right to charge a reasonable fee for the cost of producing and mailing the
copies. More information on our fee structure is available by contacting our
group Health and Dental Plan administrators at the addresses provided below.
Amendment of Protected Health Information: You have the right to ask
us to amend any protected health information about you that is contained in a
“designated record set” (see above). All requests for amendment
must be in writing to our group Health and/or Dental Plan administrators. In
certain cases, we may deny your request. For example, we may deny a request if
we did not create the information, as is often the case for medical information
in our records. All denials will be made in writing. You may respond by filing a
written statement of disagreement with us, and we would have the right to rebut
that statement. If you believe someone has received inaccurate protected health
information from us, you should inform us at the time of the request if you want
him or her to be informed of the amendment.
Accounting of Certain Disclosures: You have the right to have us
provide you an accounting of times when we have disclosed your protected health
information for any purpose other than the following: (a) payment or health care
operations; (b) as described in the section of this notice entitled “Others
Involved in Your Healthcare”; (c) disclosures that you or your personal
representative has authorized; or (d) certain other disclosures, such as
disclosures for national security purposes. All requests for an accounting must
be in writing to the administrator of our group Health and Dental Plans. We will
require you to provide us the specific information we need to fulfill your
request. This accounting requirement applies for six years from the date of the
disclosure, beginning with disclosures occurring after April 14, 2003. If you
request this accounting more than once in a 12-month period, we may charge you a
reasonable fee. More information is available on our fee structure by contacting
us at the address provided below.
Contact Information for Exercising Member Rights: You may exercise
any of the rights described above by contacting, in writing, the Privacy
Official at the following addresses.
University of Arkansas Group Health & Dental Plans
University of Arkansas System Administration
Benefit and Risk Management Services
2404 North University Avenue
Little Rock, AR 72207
Phone: 501-686-2500
Group Health Plan Administrator
QualChoice/QCA
Customer Service Department
10800 Financial Centre Parkway, Suite 540
Little Rock, AR 72211
Phone: 501-228-7111
Group Dental Plan Administrator
Delta Dental
Customer Service Department
P.O. Box 15965
North Little Rock, AR 72231
Phone: 501-835-3400
Changes To Privacy Practices
We may change the terms of our notice at any time. The new notice will be
effective for all protected health information that we maintain. We redistribute
a new Notice of Privacy Practices whenever we make a material change in our
privacy practices described in our notice.
Questions And Complaints
If you have any questions about this notice or would like an additional copy
of the notice, please contact the University of Arkansas Group Health and Dental
Plans Privacy Office at the above number or your campus Human
Resources/Personnel Office.
If you are concerned that your privacy rights may have been violated, please
follow the complaint procedures described in your plan documents or on our
website. You also have the right to complain to the Secretary of Health and
Human Services. We will not retaliate against you for filing a complaint. If you
have any questions about the complaint process, including the address of the
Secretary of Health and Human Services, contact the University of Arkansas
Health and/or Dental Plans Privacy Offices at the above numbers or your campus
Human Resources/Personnel Office.
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