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Articles
Deadline Nears for Employer Compliance
Under HIPAA
Privacy Policy Being Distributed
HIPAA Affects Some Broker Reports
June Golf Outing to Support Special Olympics
Compliance with New DOL Laws
Delta Dental Program Strives to Prevent Child
Abuse
April is National Child Abuse Prevention Month
Delta Dental Joins Fight Against Breast Cancer
Dentists Can Submit Claims Online
Free Online Publications Available for Subscribers,
Educators
Tips for Preventing Fraud
Staff Spotlight: Luhra Ebarle
Reward Program Details Available Online
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) requires healthcare plans, healthcare
clearinghouses and certain healthcare providers to
establish standards that protect the privacy of individually
identifiable health information, or Protected Health
Information (PHI).
These rules also affect employers in their role as plan sponsors and plan administrators.
The group health plans of employers whose premiums exceed $5 million annually
are subject to the HIPAA Privacy Rule on April 14, 2003. Those with annual premiums
less than that are subject to the HIPAA Privacy Rule on April 14, 2004. Plan
sponsors and plan administrators are encouraged to obtain legal counsel as to
meeting their obligations.
What is PHI?
Information in any form that is created or used by a "covered entity" and relates
to the past, present, or future physical or mental health of a person, or the
care given to the person or payment for health services, and identifies that
person, or could reasonably be used to identify the person, is PHI.
Examples of PHI include a person's name, address, Social Security number, date
of birth, telephone number, x-rays, services rendered, amounts charged and amounts
paid.
What is a "covered entity"?
Covered entities include health plans, healthcare clearinghouses and certain
healthcare providers. Delta Dental is a covered entity under HIPAA. Many employers'
self-insured plans are subject to HIPAA rules.
What is the Privacy Rule of HIPAA?
The Privacy Rule limits how covered entities can request, use and/or disclose
protected health information. It also requires that such entities limit their
requests, uses and disclosures to the minimum necessary to accomplish the task
(with some exceptions). This means that covered entities (including self-insured
[ASO/ASC] health plans) must generally request, use and disclose the least amount
of health information needed to get the job done.
How will the Privacy Rule affect employers?
Employers who are fully insured will be affected by the privacy regulations because
they limit the insurer's ability to describe PHI to the employer without an express
written authorization from the patient to give the insurer permission to release
information to the employer.
Self-insured employers will need, among other things, to review how they collect,
store, and use PHI in their day-to-day operations, and take steps to minimize
the amount of PHI asked for, used, and shared within the company in doing their
work.
According to Gillian Flynn, writing in Workforce: HR Trends & Tools for
Business Results, "The idea is to create a firewall between the plan and
the employer, so protected health information that the plan has access to is
not communicated to the employer for employment-related purposes. For example,
someone who operates the plan might become aware that an employee is receiving
healthcare services for cancer or a mental-health problem. That information cannot
be communicated to the employer because it might have an impact on a promotion
decision or compensation decision."
Employers will also need to amend their ERISA plan to reflect the need for a
firewall.
What are the penalties for non-compliance?
Companies that do not comply with HIPAA's Privacy Rule are subject to possible
criminal penalties, as well as greater civil penalties for various types of violations
of the Privacy Rule.
Where can employers get more information about HIPAA's Privacy Rule?
Copies of Standards for Privacy of Individually Identifiable Health Information
can be downloaded from the U.S. Department of Health and Human Services Offices
for Civil Rights, at www.hhs.gov/ocr/hipaa/finalreg.html.
All employers are urged to obtain legal advice to assist them in complying with
the Privacy Rule.
Information contained in this article is for informational and educational
purposes only. It does not constitute legal advice. We urge you to contact your
legal counsel for advice with respect to the interpretation of HIPAA and its
applicability to you.
Delta Dental will be distributing copies of our HIPAA Notice of Privacy Practices
to insured subscribers during April. This policy was developed as part of our
compliance with the Health Insurance Portability and Accountability Act (HIPAA),
the federal law designed to safeguard the protected health information of patients.
The law requires Delta Dental to take reasonable steps to ensure the privacy
of personally identifiable health information. The term "Protected Health Information" (PHI)
includes all individually identifiable health information transmitted or maintained
by us.
Our Privacy Notice describes the ways in which Delta Dental may use and disclose
PHI consistent with the law. It also describes patients' rights and certain
obligations we have regarding the use and disclosure of PHI.
This Privacy Rule becomes effective April 14, 2003.
HIPAA's privacy regulations will affect some reports that brokers currently
receive from Delta Dental. Reports including subscriber names and Social Security
numbers will no longer be available, or will be modified to exclude this information.
Affected reports include:
- PPO Report. Brokers will receive only a summary page.
- Eligibility Report. Brokers will receive summaries, but these will not
include subscriber names or Social Security numbers.
- Cost Containment Report. Any section that contains protected health information
(PHI) will be omitted.
Also, Delta Dental cannot give Protected Health Information over the phone
to a broker after April 14 without written authorization sent in by the member.
Clients will be able to authorize their brokers to receive PHI on their behalf,
and a form will be available on our Web site as of April 14. In addition, individuals
will be able to authorize brokers to receive PHI concerning these individuals.
That authorization form will also be on our Web site as of April 14, 2003.
The Thirteenth Annual Delta Dental Classic, which raises funds for Special
Olympics New Jersey (SONJ), will be held June 4, 2003, at Fiddler's Elbow Country
Club in Bedminster, New Jersey.
Delta Dental Plan of New Jersey is a proud sponsor of SONJ, a non-profit organization
that provides athletic training and competition for children and adults with
mental retardation.
Last year's Delta Dental Classic raised $55,000 for SONJ, bringing the total
funds raised through this annual event to more than $350,000.
For information about SONJ, go to www.sonj.org. To request information about
the Delta Dental Classic, call 973-285-4059 or e-mail jappaluccio@deltadentalnj.com.
The United States Department of Labor recently adopted regulations governing
claim adjudication and appeals for group health plans governed by ERISA (Claim
Procedure Regulations-Title 1-29 CFR 2560.503-1). The new claims and appeals
procedures apply to all ERISA plans, whether insured ("risk") or self-funded
("ASO" or
"ASC").
This process applies to all ERISA plans for which Delta Dental provides coverage
or administration. Delta Dental is also applying a similar set of processes
to non-ERISA plans for which we provide coverage on a risk basis. Some key
points include:
- Predetermination of benefits is not required. However, patients
and their dentists may request a predetermination to obtain advance information
about the plan's possible coverage of services before they are rendered.
- Patients and dentists will usually be notified in writing within 30
days if a claim is denied. If special circumstances require extra time
(not to exceed 15 days), Delta Dental will inform them in writing.
- Explanation of Benefits (EOB) forms (sometimes referred to as Adverse
Benefit Determinations) are the means used to inform patients and dentists
about why their claim was denied. EOBs also contain information about
Delta Dental's informal and formal appeals processes, as well as time limits
applicable to the processes. (To view a sample EOB, go to www.deltadentalnj.com,
click "Subscribers" and then click "View an easy-to-read description of
our Explanation of Benefits statement, PDF Format.") A summary of Delta
Dental's Benefit Determination and Appeal Process is available on our Web
site at www.deltadentalnj.com; click "Brokers," then "Compliance with New
Laws." This is also available under the Home Page "What's New" section.
Our Web site also includes a description of how subscribers or billing dentists
can request reviews of the Adverse Benefit Determination; the timeline for
such reviews; and the steps then taken by Delta Dental during the reviews.
The Web site also includes special provisions applicable only to DeltaCare
programs.
You may also obtain answers to frequently asked questions from the U.S. Department
of Labor Web site at www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html.
The news media recently reported on several horrendous cases of child abuse
in New Jersey. The real tragedy is that these are not isolated stories. In
New Jersey alone, more than 50,000 reports of child abuse and neglect are made
each year.
Who knows how many cases are not reported?
Delta Dental is working hard to protect children who may be victims of abuse.
The Delta Dental Foundation offers its PANDA (Prevent Abuse and Neglect through
Dental Awareness) educational program to those who are in regular contact with
children.
PANDA was originally created for dentists, who are well positioned to detect
child abuse. Two out of every three injuries occur to the head, face, and neck
areas, which are readily visible during a dental exam.
In recent years, the PANDA program expanded to include medical professionals,
teachers, school nurses, youth group leaders, and other community group leaders
who can assist in the fight to combat devastating patterns of abusive behavior.
PANDA presentations provide detailed information on physical and behavioral
indicators of child abuse and neglect. They also teach how to report suspected
abuse, and how to deal with the sensitive issues involved in filing a report
of suspected abuse.
"We are deeply concerned about the number of child abuse and neglect cases
reported in the state, which don't even include the many cases that go unreported," said
Lawrence A. Dobrin, D.M.D., a forensic expert with a dental practice in Roselle
Park and a spokesperson for the PANDA Coalition. "We strive to empower those
in authority with the knowledge and resources for reporting cases of suspected
abuse, to help the many children who are often defenseless."
"Nationwide, reports show that more than 879,000 children are victims of child
abuse and neglect and approximately 1,200 children die from maltreatment, many
at the hands of those who are supposed to protect them," wrote President George
Bush last April in his Presidential Proclamation announcing National Child
Abuse Prevention Month.
"Every April, communities across the country join to raise public awareness
about child abuse, to provide information about how to prevent it, and to assist
families in need of support, recovery, and encouragement," wrote the President.
Delta Dental is an annual sponsor of the Prevent Child Abuse-New Jersey (PCA-NJ)
Blue Ribbon Campaign, which takes place each April during National Child Abuse
Prevention Month.
PCA-NJ, with the help of hundreds of volunteers, distributes more than 300,000
blue ribbons throughout New Jersey. The ribbons remind people of the tragedy
of child abuse and what they can do to help prevent it.
For more information on PCA-NJ or to learn about becoming a volunteer for the
Blue Ribbon Campaign, please call (800) CHILDREN, or visit PCA-NJ's Web site
at www.preventchildabusenj.org.
For information about other programs to prevent child abuse, visit the U.S.
Department of Health and Human Services' National Clearinghouse on Child Abuse
and Neglect Information at www.calib.com/nccanch.
Delta Dental Plan of New Jersey, Inc. (DDPNJ) is known for fighting against
oral disease, but now it's joining the fight against another kind of disease:
breast cancer.
During the 2003 Delta Dental Plans Association (DDPA) annual meeting, Gay
VanBrunt, whose husband is the president of DDPNJ, will join in a fundraising
walk against breast cancer. She also chairs the event, which takes place on
Saturday, June 21. Proceeds from the walk will be donated to the National Breast
Cancer Coalition Fund, a grassroots advocacy group interested in raising funds
for research and improving access to care, including breast cancer clinical
trials.
"DDPA's annual meetings are filled with goodwill and camaraderie, and
Gay is helping to turn that spirit into a public good by participating in this
walk and collecting donations for this cause," said Diane Belle, vice
president, Corporate Communications, DDPNJ.
Many families and friends of the Delta Dental system have suffered with breast
cancer, and the event's organizers said they had been looking for something
the organization could do to help fight the disease that has touched so many.
This is the first time Delta Dental has participated in this particular charitable
event.
"We always promote the idea that oral care and general bodily wellness
are linked, and this is a great way to personify the message," Belle said.
If you would like to support this cause, please complete the pledge form below.
Delta Dental/National Breast Cancer Coalition Fund Pledge
Form
All proceeds from the walk at donated to NBCCF and are
tax-deductible as permitted by federal law. Please print
all information for acknowledgement and tax purposes. Thank
you.
Sponsor's Name:
Sponsor's Address:
City/State/Zip:
Sponsor's Phone Number (required for credit card donations):
Payment Type: Check _____
Credit Card _____ Cash _____
Please make checks payable to: National Breast Cancer Coalition
Fund (NBCCF)
VISA _____ MC _____
AX _____
Card Number:
Signature:
Expiration Date:
Please return sponsorships to:
Delta Dental Plan of New Jersey, Inc.
Attention: Breast Cancer Walk
P.O. Box 222
Parsippany, New Jersey 07054-0222
Both participating and non-participating dentists can now
submit claims directly to Delta Dental online.
Online claims submission can save dentists time and money.
Claims are processed faster, plus the system prompts users
for incomplete or inaccurate information (such as the subscriber's
Social Security number or date of birth) that could cause
processing delays. Online claims submission costs dentists
absolutely nothing to use, except for their Internet connection.
The system also protects patient privacy. Eligibility and
dental benefit information is released only to authorized
individuals. Our site uses industry standards such as firewalls
and Secure Socket Layer (SSL) technology to safeguard personal
information. It encrypts all personal information including
Social Security numbers, name, and all plan coverage and
benefit information.
Any practicing dentist in the United States may use our online
claims submission feature to submit claims to Delta Dental
Plan of New Jersey for patients covered by our Delta Dental
Plan. Dentists can access our online claims submission feature
by going to www.deltadentalnj.com, clicking "Dentists" and
logging on to "Benefits Connection." (Note: Only practicing
dentists-not subscribers-may file claims to Delta Dental
online.)
Delta Dental now offers free online newsletters for subscribers
and teachers.
Subscriber News, which comes out monthly, features
articles on dental health and wellness, as well as how
subscribers can make the most of their Delta Dental benefits.
For teachers and health educators, Wisdom Tooth comes
out quarterly. Wisdom Tooth provides resources to
help teach children about oral health.
To subscribe to Subscriber News, go to the Subscribers
section of our Web site at www.deltadentalnj.com.
To subscribe to Wisdom Tooth, go to the Kid's Club
section of our Web site.
In every profession or business, there are some who try
to take advantage of the system. The provision of healthcare
services is no different. Delta Dental recently offered the
following advice to subscribers about how they can limit
opportunities for healthcare providers (including dentists)
from committing fraud, and protect themselves from becoming
victims.
- Never sign a blank claim form.
- Keep detailed records of the treatment received and the
amounts paid.
- Ask healthcare providers what fees they charge.
- Know your benefits.
- Review your Explanation of Benefits statements carefully.
- Question healthcare providers and ask for clarification
if you see problems or inconsistencies on bills.
- Obtain detailed bills for services and check them closely
for accuracy.
- Make sure "free services" aren't charged to your benefits
provider.
- Keep your benefits identification number secure.
- Be aware that if someone says they can bill your benefits
program so that an uncovered treatment is paid for, you
are being pulled into an illegal scheme. You could lose
your job, be sued, and/or be fined, arrested, or jailed.
- Contact the authorities if you think you have knowledge
of a fraud.
To report a suspected case of fraud, Delta Dental Plan
of New Jersey can be reached at reportfraud@deltadentalnj.com.
Delta Dental also has a Fraud Hotline at 888-696-3262.
In the State of New Jersey, you can also contact the Office
of Insurance Fraud Prosecutor (OIFP) at www.njinsurancefraud.org,
or at 877-55-FRAUD (37283). The OIFP keeps all tips anonymous
and strictly confidential. In the State of Connecticut, contact
the Connecticut Department of Insurance/Insurance Fraud Unit,
P.O. Box 816, Hartford, CT 06142-8816; www.state.ct.us/cid/;
or at 860-297-3933.
"Get it to them quick, that's my philosophy," says Marketing
secretary Luhra Ebarle, talking about how she responds to
requests from brokers and account executives. "They have
a job to do, and it's my job to get them what they need,
when they need it," she says.
Luhra provides administrative and backup support to account
executives Kim White (Bergen and Hudson counties), Barbara
Strano (Essex, Morris, and Sussex counties) and Phyllis Romaine
(Middlesex, Monmouth, Ocean, and Passaic counties). "My duties
are very diverse, and include everything from sending out
renewals, to fielding requests from groups," she says.
She also answers requests directly from brokers.
The native of Kearny, New Jersey, joined Delta Dental five
years ago. "I like everything about my job," she says. "I
landed here shortly after I finished school, and I stayed."
Delta Dental offers two reward and recognition programs
for brokers.
The Broker Incentive Program provides special incentives
for brokers whose total book of insured business was between
$500,000 and $4,999,999 last year.
The Broker Override Program provides special override commission
rates for brokers who booked $5 million or more in business
with Delta Dental last year.
Complete details about these programs are available on our
Web site at www.deltadentalnj.com; click "Brokers" and "Incentive
Program."
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