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HIPAA-AS Q&A

Note: the material on this Web site is not legal advice and should not be used as legal advice. If you need legal advice, we recommend you consult your attorney.


Obtaining Information from Wellmark

Q. I am an individual Wellmark customer calling with questions about my claims. How do I obtain help over the phone with claims resolution?
A. Call the customer service number on your ID card and be prepared to verify:

  • Name, address, and ID number of the contract holder. (The ID number often is the Social Security Number but not always).
  • Name and date of birth of the patient
  • Relationship to the contract holder if you are not contract holder

According to Wellmark policy, customer service will not release specific diagnosis or procedure information over the phone to any party - even to the individual patient.

We cannot discuss issues in more detail than you provide.

 

Q. Are there limits on what information can be provided to me over the phone?
A. Yes. We cannot discuss issues in more detail than you provide. Wellmark will not disclose the diagnosis, type of service or treatment, the name of the clinicians or facilities involved.

 

Q. I am calling Wellmark on behalf of my spouse or family member for help with claim resolution. How do I obtain help over the phone with claims resolution?
A. Call the customer service number on your ID card and be prepared to verify:

  • Name, address, and ID number of the contract holder. (The ID number often is the Social Security Number but not always).
  • Patient's name and date of birth
  • Relationship of the patient to the contract holder
  • Name and relationship to the patient

We cannot discuss issues in more detail than you provide. Wellmark will not disclose the diagnosis, type of service or treatment or the name of the clinicians or facilities involved.

If you have this information from the patient and you can confirm the specific information related to the claim, Wellmark may further discuss the situation as long as that explanation does not involve disclosing additional protected health information for that patient.

 

Q. I want my spouse or a family member to be able to call Wellmark to help with claims resolution for me. What do I need to do?
A. If you want your spouse or family member to act on your behalf with respect to all your individual rights concerning your protected health information, then you may submit an authorized representative appointment form for Iowa (92K) PDF or South Dakota (64K) PDF.

 

Q. Will Wellmark accept a verbal authorization from the patient?
A. Yes. If the patient is present when the family members contacts Wellmark, we will accept a verbal authorization from the member to discuss the issue during that call.

 

Q. How long does the authorization last?
A. An oral authorization applies only to the duration of the phone call. A written authorization signed by the patient applies for the period of time the patient indicates on the form.

 

Q. What does the section on disaster relief mean to me?
A. It means that Wellmark is allowed to share medical information about you with a family member or government authorities without your permission in the case of a disaster, such as a flood or tornado.

 

Q. To whom does Wellmark release my information?
A. You may give Wellmark written authorization to use your medical information or to disclose it to anyone for any purpose. This authorization is available in the Wellmark Notice of Privacy Practices PDF (145K).

 

We may disclose your 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. For example, if a family member verifies the name of the provider, the date of service and the charge amount, we will discuss the claim status, paid date and paid amount. We will not release your diagnosis or the type of procedure or service you received.

 

Q. How do I get a list of companies or people to whom Wellmark releases my information?
A. You have the right to receive a list of instances in which Wellmark disclosed your medical information for purposes other than our normal payment or health care operations. Please refer to your Notice of Privacy Practices under the section titled Disclosure Accounting for instructions on how to obtain the list.

 

Q. What is a plan sponsor?
A. A plan sponsor is an employer or organization that offers a group health plan to its employees or members. A plan sponsor may be a director, senior executive, or other employee who does not require access to enrollees' health information to perform their day-to-day job functions.

 

Q. What information does Wellmark release to the plan sponsor?
A.
Typically Wellmark only releases "de-identified" or aggregate summary health information to a plan sponsor. A plan sponsor may also receive information concerning enrollment in the health plan.

 

Q. What information is contained in the medical information that Wellmark releases?
A. For large group health plans, Wellmark may provide aggregate health information showing how the plan members have utilized the health plan. For example, a report we provide group health plans during the annual renewal period shows the total amount of covered charges submitted in claims for inpatient, outpatient, office and other health care in comparison to the same categories for the prior year.

Wellmark Privacy Compliance

Q.Who do I contact if I have a privacy-related question or issue?
A. You may contact Wellmark's Privacy Office:

Mailing Address:
Wellmark, Inc.
Privacy Office, Station 4W777
P O Box 9232
Des Moines IA 50306-9232

  

Telephone:
877-610-6395 Outside Des Moines Area
515-376-5850 Des Moines Local Area

 

Fax:
515-376-9032

 

Email:
privacyoffice@wellmark.com

Q. Does Wellmark intend to comply with all elements of the Privacy Regulation, including the items listed below?

  • Erection of physical barriers and electronic firewalls to safeguard protected health information (PHI)
  • Process to provide individuals with access to their PHI in a designated record sets
  • Process for individual to request an amendment to their information, request restrictions and confidential communications
  • Receipt of "authorizations" from individuals as needed
  • Process for individuals to lodge complaints, handle complaints and track complaint-resolution
  • Reporting to customers any improper use or disclosure of PHI
  • Requiring subcontractors and others to comply with HIPAA-AS privacy regulations
  • Retaining designated record sets according to applicable insurance laws?

A. Yes. Please see Wellmark Notice of Privacy Practices for additional information


Q. Has Wellmark published its policies and procedures regarding HIPAA-AS privacy compliance?
A. Yes. Please see Wellmark Notice of Privacy Practices for additional information


Q. Is Wellmark's Notice of Privacy Practices available upon request?
A. Yes. Please see Wellmark Notice of Privacy Practices for additional information


Q. How will Wellmark respond to my request to inspect, copy or change my protected health information or receive an accounting of disclosures after April 14, 2003?
A. How the individual obtains the PHI depends on whether he/she is covered under a fully-insured health plan or a self-funded health plan arrangement. Please read the next two questions.

If you are enrolled in a fully insured plan:
To inspect, copy or change information: Wellmark customers will submit their requests to Wellmark. The request process is outlined in the Wellmark Notice of Privacy Practices. 

To request a designated record set: Wellmark customers will submit their requests to Wellmark. Wellmark will charge the member of a fully-insured health plan a cost-based fee for each request. The fee will be requested at the time the request is submitted. The request process is outlined in the Wellmark Notice of Privacy Practices. 

 

To receive an accounting of disclosures: Customers will submit their requests to Wellmark. Wellmark will provide the first accounting in a 12-month period at no charge to the member. For each additional request, Wellmark will charge the customer a cost-based fee for each request. The fee will be required at the time the request is submitted. The request process is outlined in the Wellmark Notice of Privacy Practices. 

 

If you are in a self-insured group health plan:
The customer should contact that health plan which will have its own procedures for answering the requests. The customer may want to contact his/her Human Resources department for information.

 

Q. How do I know if my health plan is fully insured or a self-funded health plan with Wellmark?
A. If you receive a Notice of Privacy Practices from Wellmark, you have fully insured plan with Wellmark You also can contact your employer's Human Resources department

Notice of Privacy Practices

Q. Who is supposed to receive the Wellmark Notice of Privacy Practices?
A. Wellmark is sending its Notice of Privacy Practices to contract holders who are enrolled through fully-insured health plans, including direct-pay or Medicare Supplement plans.

Individuals enrolled in self-funded health plans will receive a Notice of Privacy Practices document from those self-funded group health plans.

 

Q. Will Wellmark send me more than one Notice of Privacy Practices?
A. Wellmark sent one copy of its Notice of Privacy Practices to each enrolled contractholder by April 14, 2003. After that, we must provide the Notice to each new contractholder upon enrollment, and Wellmark must advise its contract holders of the availability of the Notice every three years.

 

You might receive a Notice from Wellmark and a Notice from another insurance plan if your health plan benefits are provided by more than one plan.

 

Q. Does Wellmark send the Privacy Notice for its fully-insured accounts?
A. Yes.

 

Q. Does Wellmark send the Privacy Notice for its self-funded accounts?
A. No.

 

Q. Does Wellmark require a review of the privacy policies and procedures for self-funded accounts?
A. No.


Quick Links

Authorization to Use or Disclose Protected Health Information
»   Individual Authorization - Iowa - #S-53258 pdf image
»   Individual Authorization - South Dakota - #S-3315 pdf image
»   Designation of Authorized Representative - Iowa
- #S-53257 pdf image
»   Designation of Authorized Representative - South Dakota - #S-3316 pdf image
Authorized Representative Appointment and Authorization for Release of Information
»   Iowa - #C-5674 pdf image
»   South Dakota - #C-3617 pdf image
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