1. Privacy and Information Practices
We at Delta Dental Plan of New Jersey, Inc. (“Delta Dental Plan”) and Delta Dental Insurance Company (“DDIC”), for whom Delta Dental Plan 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 dentist's 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 (including "HIPAA," i.e. the Health Insurance Protection and Accountability Act of 1996). 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 have agreed to protect the confidentiality of the information) 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
A summary of our medical record policies, standards and procedures as they relate to persons (a) for whom Delta Dental Plan provides enrollment and claims administration and (b) covered by Delta Dental Plan of New Jersey, Inc. and/or Delta Dental Insurance Company follows.
4. HIPAA Notice of Privacy Practices for Protected Health Information
We maintain a separate Notice of Privacy Practices for Protected Health Information as required by HIPAA and provide that notice to our primary subscribers when they obtain coverage with us. A copy of that HIPAA Privacy Notice is available on our HIPAA web page, Notice of Privacy Practices. You may also obtain a copy from our Compliance Manager by calling 866-861-4716, e-mail to firstname.lastname@example.org, or mail to P.O. Box 222, Parsippany, New Jersey 07054.
Summary of Policy Concerning Privacy of Protected Information for Insured Contracts Issued in
New Jersey and Connecticut
"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 Plan 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 Plan 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 Plan's provision of dental coverage to such persons. Under no circumstances are Delta Dental Plan 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 Plan.
4. Handling, Storage, and Disposal of Protected Information
Delta Dental Plan 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 Plan'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 Plan.
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 Plan associate whose job responsibilities include disclosing Protected Information to disclose such information:
(1) Pursuant to an individual's request if Delta Dental Plan 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 Plan. 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 Plan, or (b) is reasonably necessary for such person to perform his function for Delta Dental Plan; 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 Plan 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 Plan 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 and which may impact their treatment decision; 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 Plan's interests or its policyholder in preventing or prosecuting the perpetration of fraud upon it; or (b) if Delta Dental Plan 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 Plan'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 Plan whose only use of the information will be in connection with an audit of Delta Dental Plan or the marketing of Delta Dental Plan 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 Plan 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.
Where federal law (e.g. the HIPAA Privacy Rule) is more restrictive, we will limit our request for, use of, and/or disclosure of Protected Information so as to comply with such federal law.
7. Periodic Monitoring of Compliance
8. Your State Law Right to Access Protected Information
You may request access pursuant to state law to Protected Information which we can reasonably locate and retrieve. To exercise this state law right, you must properly identify yourself to us and submit a written request for state law access to our Compliance Manager at the address listed in No. 10 below. Within thirty business days from our receipt of the request we will respond to your request.
Our response will inform you in writing of the nature and substance of the recorded Protected Information which we were reasonably able to locate and retrieve, permit you to review it, and, if you wish a copy, provide a copy to you upon payment of a reasonable fee for such copying. We will also disclose to you the identity of the recipients of your Protected Information within the two year period preceding your request (to the extent that such recipients were recorded and that data was reasonably locatable and retrievable by us) as well as the identities of those entities (such as our subcontractors) to whom such Protected Information is normally disclosed. We are not, however, required to provide information to you that relates to and was collected in connection with or in reasonable anticipation of a claim or civil or criminal action involving you.
9. Your State Law Right to Request Correction, Amendment, or Deletion of Recorded Protected Information
You may request correction, amendment, or deletion of recorded Protected Information about you in our possession. To exercise this state law right, you must properly identify yourself to us and submit a written request for state law correction, amendment, or deletion of recorded Protected Information to our Compliance Manager at the address listed in No. 10 below. Within thirty business days of our receipt of the request we will either honor the request or notify you of our decision not to make the requested correction, amendment or deletion, the reason(s) for our decision and your right to file a statement with us relating to the disagreement.
If we honor the request, we will so notify you in writing and we will furnish the correction, amendment or fact of deletion to any person you specifically designate to us who had received the recorded Protected Information within two years prior to your request and, if applicable, any insurance-support organization that previously furnished the information to us which was corrected, amended or deleted as well as any insurance-support organization (if any) that systematically received such recorded Protected Information from us within the preceding seven year period.
If we decided not to make the requested correction, amendment or deletion and you disagree, you may file with us a concise statement of what you think is correct, relevant or fair information and explain why you disagree with our decision. In that event, we will file your statement and provide a means for anyone viewing the disputed Protected Information to be aware of and have access to it, provide your statement to any subsequent recipients of the disputed Protected Information and furnish the statement to any insurance-support organization that previously furnished the information to us which was corrected, amended or deleted as well as any insurance-support organization (if any) that systematically received such recorded Protected Information from us within the preceding seven year period.
Your right to request correction, amendment or deletion of Protected Information does not extend to information about you that relates to and is collected in connection with or in reasonable anticipation of a claim or civil or criminal proceeding involving you.
Delta Dental Plan of New Jersey, Inc.
Attn: Compliance Manager.
P.O. Box 222
Parsippany, New Jersey 07054