Responsibilities for Self-Funded Group Health Plans

Note: The material on this web site is not legal advice and should not be used as legal advice. If you need legal advice upon which you can rely, we recommend you consult your attorney.

  • Wellmark is a business associate of the self-funded health plan by providing administrative services for the plan and must provide assurance that we will safeguard and limit the use and disclosure of protected health information
  • The business associate contract includes the terms for Wellmark to provide administrative services only for a self-funded health plan
  • A self-funded health plan must identify the individuals in the organization who represent the health plan and are authorized to request and receive PHI
  • If the employer plan sponsor receives ONLY SUMMARY HEALTH INFORMATION, the plan document does not need to be amended
  • HOWEVER – if the employer plan sponsor requires PHI to administer the health plan, the plan documents must be amended to include the provisions required by the Privacy Regulation

Designated Record Set

After April 14, 2003, an individual may request his or her "designated record set" (DRS). The DRS includes information collected on or after April 14, 2003, and is used to make health care decisions or determine whether an insurance claim will be paid, including:

  • Enrollment
  • Payment
  • Claims Adjudication
  • Case or medical management records

The DRS includes all health information records maintained by Wellmark, including enrollment applications, attending physician statements and all claims-related documentation for a period of six years (starting April 14, 2003).

 

The HIPAA-AS privacy rules require Wellmark to accommodate an individual's request for a copy of his/her DRS.

 

For a self-funded group health plan, Wellmark will charge the group a cost-based fee for each request.

 

The fees will be added to the self-funded plan's monthly statement.

 

The self-funded plan may pass this charge on to its member by charging a cost-based fee for each request.

 

Accounting of Disclosures

The HIPAA-AS privacy rules require Wellmark to provide an accounting of the disclosures of an individual's protected health information, if requested, over the previous six years starting April 14, 2003.

 

Wellmark is not required to account for disclosures that occur due to normal payment and health care operations.

 

For a self-funded health plan, Wellmark will charge the group a cost-based fee for every request.

 

The fees will be added to the self-funded plan's monthly statement.

 

The plan is not allowed to charge its member for the first accounting in a 12-month period.

 
 
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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
 
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