«Partnership HealthPlan of California Medi-Cal Member Handbook Together for your Health Our Service Area Del Norte, Humboldt, Lake, Lassen, Marin, ...»
In the Event of a Serious Threat to Health or Safety: PHC may, consistent with applicable law and ethical standards of conduct, disclose your health information if PHC, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Specified Government Functions: PHC may make disclosure to authorized federal officials in national security activities or for the provision of protective services to officials.
For Workers Compensation: PHC may release your health information for worker’s compensation or similar programs.
To a Correctional Institution or to a Law Enforcement Official: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the institution or official To other agencies administering government health benefit programs, as authorized or required by law For Immunization Purposes: To a school, about a member who is a student or prospective student of the school, but only if: (1) the information that is disclosed is limited to proof of immunization; (2) the school is required by the State or other law to have such proof of immunization prior to admitting the member; and (3) there is documented agreement by the member or the member’s guardian.
For underwriting or related purposes, such as premium rating or other activities related to the creation, renewal or replacement of a contract of health insurance or benefits as required by law, but may not include genetic information.
Can others involved in my care receive information about me?
Yes, we may release health information to a friend or family member who is involved in your care, or who is paying for your care, to the extent we judge it necessary for their participation unless you specifically ask us not to and we agree to that request. This includes responding to telephone enquiries about eligibility and claim status.
OTHER THAN WHAT IS STATED ABOVE, PHC WILL NOT DISCLOSE YOUR
HEALTH INFORMATION OTHER THAN WITH YOUR WRITTEN
AUTHORIZATION. IF YOU OR YOUR REPRESENTATIVE AUTHORIZES PHC TO
USE OR DISCLOSE YOUR HEALTH INFORMATION, YOU MAY REVOKE THAT
AUTHORIZATION IN WRITING AT ANY TIMEAre there instances when my health information is not released?
We will not permit other uses and disclosures of your health information without your written permission, or authorization which you may revoke at any time in the manner described in our authorization form.
Except as described above (How does Partnership HealthPlan of California use and disclose my health information), disclosures of psychotherapy notes, marketing and the sale of your information require your written authorization and a statement that you may revoke the authorization at any time in writing.
Your Individual Rights What rights do I have as a PHC member?
As a PHC member you have the following rights with respect to your health information:
To ask us to restrict certain uses and disclosures of your health information. PHC is not required to agree to any restrictions requested by its members unless the disclosure is for the purpose of carrying out payment or health care operations and the request is solely for a health care item or service for which you, or another person other than PHC, has paid for the service(s) out of pocket.
To receive confidential communications from PHC at a particular phone number, P.O.
Box, or some other address that you specify to us.
To see and copy any of your health records that PHC maintains on you, including billing records, we must receive your request in writing. We will respond to your request within 30 days. We may charge a fee to cover the cost of copying, assembling and mailing your records, as applicable. You may also request PHC to transmit the information directly to another person if your written request is signed by you and clearly identifies both the designated person and where to send the information. In some situations, we may ask if you would agree to receive a summary or an explanation of the requested information and to any fees that might be imposed to create it. Under certain circumstances, PHC may deny your request. If your request is denied, we will tell you the reason why in writing.
You have the right to appeal a denial.
If you feel the information in our records is wrong, you have the right to request us to amend the records. We may deny your request in certain circumstances. If your request is denied, you have the right to submit a statement for inclusion in the record.
You have the right to receive a report of non-routine disclosures that we have made of your health information, up to six years prior from the date of your request. There are some exceptions: for example, we do not maintain records of disclosures made with your authorization; disclosures made for the purposes of health care treatment, determining payment for health services, or conducting the health plan operations of PHC; disclosures made to you; and certain other disclosures.
If you received this notice electronically, you have the right to request a paper copy from us at any time.
How do I exercise these rights?
You can exercise any of your rights by sending a written request to our Privacy Official at the address below. To facilitate processing of your request, we encourage you to use our request form, which you can obtain from our Internet website at www.partnershiphp.org or by calling us at the telephone number below. You can also obtain a complete statement of your rights, including our procedures for responding to requests to exercise your rights, by calling or writing to the Privacy Official at the address below.
How do I file a complaint if my privacy rights are violated?
As a PHC member, you or your personal representative have the right to file a complaint with our Privacy Official if you believe your privacy rights have been violated. You or your representative must provide us with specific written information to support your complaint; see contact information below. You may also file a complaint with the Secretary of Health and
Human Services on their website or use the contact information listed below:
PHC encourages you to contact us with any concerns you have regarding the privacy of your information. PHC will not retaliate against you in any way for filing a complaint. Filing a complaint will not adversely affect the quality health care services you receive as a PHC member.
Telephone Number: (800) 863-4155 or TTY/TDD (800) 735-2929 or call 711 PHC's Complaint Hot-Line is (800) 601-2146 and is operated 24 hours a day, 7 days a week
California's Department of Health Care Services:
Section 17 – Help PHC Stop Fraud, Waste and Abuse Learn about helping stop Fraud, Waste and Abuse.
PHC, as your health plan, is responsible for getting you the health care you need. Getting health care means you have to present certain information at your provider’s office when you have an appointment.
This helps PHC and your medical provider provide the right service at the right time. It also helps keep the Medi-Cal program free of fraud, waste and abuse. Below we describe what fraud, waste and abuse is and how you can help fight it.
Fraud Fraud includes, but is not limited to, intentionally using someone else’s medical benefits for your health care services, intentionally using someone else’s social security number to qualify for government assistance or intentional billing by the provider for services that did not occur. If you commit fraud you may lose your Medi-Cal coverage.
Waste Waste is the use, throwing away or spending of health care or government resources in an
unwise and wrong manner. Examples of waste include:
Prescribing more medication than is medically necessary Providing more health care services than is medically necessary Abuse
Abuse is the misuse of health care or government resources. Examples of abuse include:
Requesting and obtaining medications or medical equipment you do not need to use for your benefit Billing from the provider for services that did not occur How to report Fraud, Waste and Abuse If you suspect someone of using your information or committing fraud, waste or abuse, please call PHC’s Compliance Hotline at (800) 601-2146. This number is available 24 hours a day, 7 days a week.
You can also call PHC’s Member Services Department to report the issue at (800) 863-4155 or
you could call:
The Department of Health Care Services Fraud & Abuse Hotline at (800) 822-6222 The Department of Justice Office of the Attorney General Bureau of Medi-Cal Fraud & Elder Abuse at (800) 722-0432 Why should you care about Fraud, Waste and Abuse?
Health care fraud, waste and abuse are serious issues. Fraudulently received benefits or services impact the cost of health care services.
Preventing health care fraud
Here are a few helpful tips on what you can do to help prevent health care fraud:
Do not give your ID card or ID card number to anyone except your provider, clinic, hospital, health care provider or health plan.
Never give your social security card to anyone Never sign a blank insurance claim form Beware of anyone who offers you free medical services in exchange for your ID card.
You should never give away your ID card to anyone in exchange for free medical services.
If it sounds too good to be true, it probably is. Be careful about accepting other medical services not covered by Medi-Cal when you are told they will be free of charge.
Section 18 – Glossary Learn more about the names and words we use in this handbook.
This section of the Handbook gives you explanations for some of the terms and names we have used.
If you need help understanding this Handbook, call PHC’s Member Services Department at (800) 863-4155.
A Appeal is something you do if you disagree with our decision to deny a request for a benefit or service, including prescription drugs. You can also appeal a decision by PHC to stop covering a benefit you are already receiving. See Section 12 of this Handbook for more information.
B Brand Drug is a prescription drug that is made and sold by the company that originally researched and developed the drug. Brand drugs are usually more expensive than generic drugs even though brand name drugs have the same active ingredient formula as the generic drug.
C Complaint is when you tell us you don’t like something about your PHC membership, including concerns about the quality of care you get from providers.
Covered Services means all of the services PHC covers, including prescription drugs, PCP visits and hospitalization. To see a full list of what PHC covers and what other programs may cover see Section 9 of this Handbook.
D Denial is when PHC decides not to cover a benefit or service that has been requested by you or your provider. When PHC denies a benefit or service, you and your provider will receive a Notice of Action (NOA). To learn more, look up Notice of Action in this Section or see Section 12 of this Handbook for more information.
Deferral is when PHC, you or your provider has asked for more time to review a request for a benefit or service. More time is usually asked for to make sure PHC has all of the information it needs to review a request for a benefit or service. When more time is needed, PHC will send a Notice of Action (NOA) to you and your provider. To learn more, look up Notice of Action in this Section, or see Section 12 of this Handbook for more information.
Durable Medical Equipment (DME) means certain medical equipment that is ordered by your provider for medical reasons. Examples are walkers, wheelchairs or hospital beds. To see what PHC covers for DME see Section 9 of this Handbook for more information.
E Emergency means a condition that you feel could lead to disability or death if not immediately treated. It can also be a condition that is causing you severe pain, or is quickly getting worse. An emergency can also be psychiatric (mental health) related, including having thoughts or actions about hurting yourself or someone else, or being unable to care for yourself. See Section 7 of this Handbook for more information.
Emergency Care is when you are treated in an emergency room of a hospital for an emergency condition. See Section 7 of this Handbook for more information.
Enrollment can mean 1) your joining PHC, or 2) your assignment to a PCP. Usually when we talk about enrollment, we mean when you become a PHC member.
Evidence of Coverage (EOC) is the document you are reading right now. This EOC tells you what is covered, what PHC must do, your rights, and what you need to do as a member of our plan.
F Federally Qualified Health Center (FQHC) is a type of Health Center that can provide you primary care and other types of health care. See Section 3 of this Handbook for more information.
G Generic Drug is a prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as a brand name drug. Generally, a generic drug works the same as a brand name drug and usually costs less.
Grievance is used to describe both complaints and appeals, and is when you disagree with a decision by PHC, or how you were treated by PHC or your provider.
H Home County means the county that you live in. This is important because, except for certain cases, you must see providers in your Home County. See Section 3 of this Handbook for more information. Some services are covered outside of your Home County, like urgent and emergency care.