Notice of Privacy and Information Practices

1.  Privacy and Information Practices

We at Delta Dental of New Jersey, Inc. (“Delta Dental”) and Delta Dental Insurance Company (“DDIC”), for whom Delta Dental provides enrollment and claims administration in Connecticut, value the privacy of individuals for whom we provide dental coverage and claims administration.

In order to properly and accurately establish and update eligibility for dental coverage, process claims and requests for predeterminations of benefits, provide customer service, respond to dental providers’ requests for information to enable them to serve our covered persons, issue accurate invoices to our policyholders, and comply with all applicable state and federal laws (collectively, our “dental benefit administration activities”), we gather individually identifiable information relating to the persons for whom we provide or administer dental benefit coverage. This information includes individuals’ names, addresses, dates of birth, gender, marital status, social security numbers, and the dental services such individuals seek and/or have previously sought or obtained (collectively “personal information”).

We receive personal information from various sources. They include: group policyholders who contract with us to provide and/or administer dental coverage for their employees, members and/or dependents and sometimes the policyholders’ brokers, consultants and/or administrators. Other sources of personal information include the covered individuals themselves, their dentists, and other entities which have provided coverage for dental services rendered to them and third parties.

First, we are proud to tell you that we do not provide our covered persons’ personal information to anyone (including our affiliates) for marketing purposes or for any purpose other than a dental benefit administration activity or other purposes authorized by law.  Whenever we provide data for research or similar uses, we remove all information which would enable anyone to identify the person to whom the information relates consistent with all applicable state and federal laws. Because we do not disclose your individually identifiable non-public personal information to anyone affiliated or non-affiliated with us for purposes other than dental benefit administration activity, and do not wish to retain the right to do so, you need not “opt out” of any such practice.

We disclose personal information about our covered persons only where it is necessary or appropriate in fulfillment of our dental benefit administration activities and only when such disclosure is consistent with all applicable state and federal laws. Examples of our disclosures include: the notices of payment which we transmit to our covered persons and their dentists in response to dental claims which they have submitted to us; the predeterminations we issue to our covered persons and their dentists in response to their requests; other communications with our covered persons and their dentists in connection with the processing of claims and predeterminations, such as responding to inquiries concerning eligibility, dental coverage, limitations and exclusions, and our resolution of claims and requests for predeterminations; communications with our policyholders and their representatives concerning eligibility and in some instances receipt of and/or resolution of claims; communications with other insurance carriers or claims administrators relating to the interaction of the two plans’ coverages, payments and/or exclusions; communications relating to our activities to deter, identify and pursue potential fraud and abuse; disclosure to third parties who contract with us to assist in our dental benefits administration activity, such as data entry services and check processing (who agree to keep the information confidential); and other disclosures required or permitted by law (e.g. reports of suspected insurance fraud, responses to subpoenas, review by state and federal governmental entities, etc.).

2.  Confidentiality and Security

In compliance with state and federal standards, as well as our own commitment to privacy, we maintain physical and electronic safeguards to protect nonpublic personal information.  Policies and procedures have also been implemented which limit access to this information on a “need to know” basis.

3.  Summary of Medical Record Policies, Standards and Procedures

1. Introduction

This is a summary of the Privacy Policy of Delta Dental of New Jersey, Inc. (“Delta Dental”). It is intended for the information of persons: (a) covered by Delta Dental Insurance Company (“DDIC”) in Connecticut where Delta Dental provides enrollment and claims administration and (b) covered by Delta Dental of New Jersey. It is only a summary. The entire policy statement is maintained at Delta Dental of New Jersey, Inc. 

2. Definitions

"Protected Information" means any information which is within the scope of the definitions of "Medical Record Information," "Personal Information," and/or "Privileged Information" as defined below. "Medical Record Information" means personal information which Delta Dental has collected or received which either relates to an individual's physical or mental condition, medical history, medical treatment, claims submitted or paid for medical treatment, or is obtained from a medical professional or medical-care institution from the individual, or from the individual's spouse, parent or legal guardian. "Personal Information" means any individually identifiable information gathered in connection with the determination of an individual's eligibility for dental coverage, benefit or payment or the servicing of any application for dental coverage or of a policy, contract or certificate. "Privileged Information" means any individually identifiable information that relates to a claim for dental benefits or a civil or criminal proceeding involving an individual and is collected in connection with or in reasonable anticipation of a claim for dental benefits or a civil or criminal proceeding involving the individual.

"Sensitive Health Information" means information concerning an individual's sexually transmitted disease(s); mental health; substance abuse; human immuno deficiency virus; acquired immunity deficiency syndrome; pregnancy; and genetic testing and/or the results thereof.

3. Accessing Medical Record Information

Delta Dental personnel will access Protected Information only for purposes of: determining eligibility for dental coverage; processing claims; processing requests for predetermination of benefits; responding to inquiries concerning claims and requests for preauthorization; investigations; and other transactions or matters which relate to DDIC’s or Delta Dental's provision of dental coverage to such persons. Under no circumstances are Delta Dental personnel permitted to access Protected Information for their private use or with the intention to use it for a purpose not related to the fulfillment of that person's job responsibilities for Delta Dental.

4. Handling, Storage, and Disposal of Protected Information

Delta Dental associates are required to use reasonable care in the handling, storage, and disposal of Protected Information so as not to enable unauthorized access, use or disclosure. All Medical Record Information maintained on hard copy is to be shredded prior to disposal. All Medical Record Information maintained electronically is to be erased prior to disposal. Sensitive Health Information is to be expurgated whenever feasible unless it is essential to Delta Dental's processing of the claim or other business purpose. Sensitive Health Information may not be copied or released without the authorization of a department head at Delta Dental.

5. Use and Disclosure of Protected Information

The following is a summary of the types of conditions, any of which would permit a Delta Dental associate whose job responsibilities include disclosing Protected Information to disclose such information:

(1)  Pursuant to an individual's request if Delta Dental possesses the signed written authorization of the individual and that authorization is dated within one year prior to the date of disclosure; or

(2)  To a person other than an insurance carrier or its agent if it is reasonably necessary to enable such person to perform a business, professional or insurance function for Delta Dental. Before making such a disclosure, the recipient of the information must agree not to disclose the information without the individual's written authorization unless the disclosure (a) would otherwise be permitted by Delta Dental, or (b) is reasonably necessary for such person to perform his function for Delta Dental; or

(3)  To a person other than an insurance carrier or its agent if it is reasonably necessary to enable such person to provide information to Delta Dental for the purpose of (a) determining an individual's eligibility for an insurance benefit or payment, or (b) detecting or preventing criminal activity, fraud, material misrepresentation or material nondisclosure in connection with an insurance transaction; or

(4)  To an insurance carrier or self-insurer if the information disclosed is limited to that which is reasonably necessary:

(a) to detect or prevent criminal activity, fraud, material misrepresentation or material nondisclosure in connection with insurance transactions, or

(b) for either DDIC, Delta Dental or the recipient to perform its function in connection with an insurance transaction involving the individual; or

(5)  To a dental office or medical professional for the purpose of:

(a) verifying insurance coverage or benefits;

(b) informing an individual of a medical problem of which he may not be aware; or

(c) conducting an operations or services audit, provided only such information is disclosed as is reasonably necessary to accomplish the foregoing purposes;

(6)  To an insurance regulatory authority;

(7)  To a law enforcement or other government authority:

(a) to protect DDIC’s and/or Delta Dental's interests or its policyholder in preventing or prosecuting the perpetration of fraud upon it; or

(b) if Delta Dental reasonably believes that illegal activities may have been conducted by the individual;

(8)  As otherwise permitted or required by law;

(9)  In response to a facially valid administrative or judicial order, including a search warrant or subpoena with the approval of Delta Dental's General Counsel;

(10)  For the purpose of conducting actuarial or research studies, provided:

(a) no individual may be identified in any actuarial or research report;

(b) materials in which the individual may be identified are returned or destroyed as soon as they are no longer necessary; and

(c) the actuarial or research organization agrees not to disclose the information unless the disclosure would otherwise be permitted by this section if made by an insurance institution, agent or insurance-support organization;

(11)  To an affiliate of Delta Dental whose only use of the information will be in connection with an audit of Delta Dental or the marketing of Delta Dental products or services provided the affiliate agrees not to disclose the information for any other purpose or to unaffiliated persons;

(12)  To a DDIC and/or Delta Dental group policyholder for the purpose of reporting claims experience or conducting an audit of its or its agent's operations or services, provided the information disclosed is reasonably necessary for the recipient to conduct the audit;

(13)  To a professional peer review organization for the purpose of reviewing the service or conduct of a dentist or medical professional; or

(14)  To a governmental authority for the purpose of determining the individual's eligibility for health benefits for which the governmental authority may be liable;

(15)  To a covered person or group policyholder for the purpose of providing information regarding the status of a claim or predetermination request.

6. Training

All Delta Dental associates receive initial privacy training and must annually review Delta Dental's Policy Statement Concerning Privacy. Any Delta Dental associate who is believed to have violated the policy is to receive supplemental instruction concerning the policy and how it relates to that individual's responsibilities at Delta Dental. Disciplinary action will be taken in the event of any additional violation. Furthermore, in the event that any Delta Dental associate willfully and deliberately violates Delta Dental's privacy policy, the individual's employment may be immediately terminated.

7. Periodic Monitoring of Compliance

Delta Dental department heads are required to monitor no less frequently than annually the compliance with the Policy Statement by all personnel within each department. That monitoring is to be tailored to the actual operation of each respective department and will at a minimum include review of all signed acknowledgements by Delta Dental associates that they have read the Privacy Policy and review of all supplemental training of Delta Dental associates to determine whether there is a need for any additional privacy training.

8. Questions

If you have any questions concerning this privacy policy or any suggestions, please submit them in writing to Delta Dental of New Jersey, Inc., 1639 Route 10, Parsippany, New Jersey  07054, Attention: Compliance Administrator.