Who Can Access an Explanation of Benefits?
An Explanation of Benefits (EOB) outlines in detail the benefits a contract holder or policyholder is eligible for under their health insurance plan. The contract holder/policyholder may receive EOBs for all persons covered under the plan.
Right of Access to Information Under the Privacy Regulation
The right to inspect or receive copies of protected health information (PHI) is limited to the individual who is the subject of the information or a legal personal representative including:
- The natural or adoptive parent of a minor child (unless restricted by court order or custody agreement)
- Executor for a deceased individual
- Court appointed guardian or power of attorney (with authority granted to access health information or make health-related decisions)
- A person named as a personal representative by written authorization from the subject individual
The following are not considered legal personal representatives with regard to the above noted right to access:
- A parent of an adult child (18+)
- A spouse
- A step parent
Regardless of the relationship to the individual, the release of information concerning birth control, alcohol or chemical dependency and mental nervous treatment is subject to specific restrictions and requirements under state and federal law.
Routine Customer Service Inquiries Over the Phone
Persons involved in the care or payment for care for a member are referred to as advocates acting on behalf of a member. A person in this capacity must provide the following information in order to confirm their identity and authority:
- Caller’s name and relationship to the member
- Contract holder’s name and ID number
- Address of the contract holder
- Member or contract holder’s date of birth
- Specific claim detail (if applicable to request)
For example, in order to provide claim status or claim payment information, the caller must be able to verify the name of the provider, date of service, amount of charge and type of service. Regardless of who is calling, we do not release diagnosis or specific procedure information over the phone.
Privacy of Members' Medical Information
Wellmark is required by applicable federal and state laws to maintain the privacy of our members’ medical information. Wellmark is required to give our members notice about our privacy practices, our responsibilities and members’ rights concerning their medical information. The business affairs and records of our company are confidential. They are not to be shared with anyone inside or outside the company, except for those who need to know in order to conduct the business of our company.
The steps Wellmark has taken to safeguard members’ medical information include but are not limited to:
- Distributed a Privacy Practices Notice (838KB) to insured members, practitioners, and facilities; included the notice in the provider newsletter Blue InkSM; and posted the notice on wellmark.com
- Established a Privacy Office as a primary point of contact concerning questions or issues regarding privacy matters.
- Established internal policies and procedures for compliance with the Privacy Rule and disseminated the information to employees through corporate-wide privacy training and department-specific training for customer service and other areas
- Required all of Wellmark's workforce to sign a Confidentiality and Nondisclosure Agreement as a condition of their employment
- Instituted procedures for Wellmark provider and customer service representatives to verify the identity and authority of callers prior to discussing protected health information
- Limited physical and information system access to medical information to people who need it to do their jobs
Maintained strict security regarding access to facility, personal computers and medical information