Payment: Payment includes activities undertaken to obtain Plan contributions or to determine or fulfill the Plan’s responsibility for provision of benefits under the Plan, or to obtain or provide reimbursement for health care. Payment also includes: 1. Eligibility and coverage determinations, including coordination or benefits and adjudication or subrogation of health benefit claims; 2. Risk adjusting based on enrollee status and demographic characteristics; and 3. Billing, claims management, collection activities, obtaining payment under a contract for reinsurance (including stop-loss insurance and excess loss insurance) and related health care data processing. PHI may be disclosed for purposes of the Plan’s own health care operations. PHI may be disclosed to another covered entity for purposes of the other covered entity’s quality assessment and improvement, case management, or health care fraud and abuse detection programs, if the other covered entity has (or had) a relationship with the participant and the PHI requested pertains to that relationship. 1. Health Care Operations: Health care operations means any of the following activities to the extent that they are related to Plan administration: a. Conducting quality assessment and improvement activities; b. Reviewing health plan performance; c. Underwriting and premium rating; d. Conducting or arranging for medical review, legal services, and auditing functions; e. Business planning and development; and f. Business management and general administrative activities. No Disclosure of PHI for Non-Health Plan Purposes: PHI may not be used or disclosed for the payment or operations of the District’s “non-health” benefits (e.g., disability, workers’ compensations, life insurance, etc.), unless the participant has provided an authorization for such use or disclosure (as discussed in “Disclosures Pursuant to an Authorization”) or such use or disclosure is required by applicable state law and particular requirements under HIPAA are met. Mandatory Disclosures of PHI: to Individual and Department of Health & Human Services (DHHS): A particular PHI must be disclosed as required by HIPAA in two situations: 1. The disclosure is to the individual who is the subject of the information (see the policy for “Access to Protected Information and Request for Amendment” that follows). 2. The disclosure is made to DHHS for purposes of enforcing of HIPAA. PHI may be disclosed in the following situations without a participant’s authorization, when specific requirements are satisfied: 1. About victims of abuse, neglect, or domestic violence; 2. For judicial and administrative proceedings;
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