Glossary

Authorization

An individual member's written permission to use their PHI for purposes other than treatment, payment or operations or to disclose PHI to a third party specified by the individual.

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Business Associate

A person or entity engaged to assist BCBSM or BCN in performing certain functions or services on our behalf, and in that capacity receives, uses and/or discloses PHI.

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Covered Entity

Refers to a health care provider, health plan or health care clearinghouse.

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De-identified Health Information

Health information that does not identify an individual and where there is no reasonable basis to believe that the information can be used to identify an individual. There are two ways to de-identify information, either 1) a formal determination by a qualified statistician; or 2) the removal of specified identifiers of the individual and of the individual's relatives, household members, and employees is required, and is adequate only if the covered entity has no actual knowledge that the remaining information could be used to identify the individual. De-identified data may be used or disclosed without restriction.

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Disclose

To release, transfer, send or provide access to PHI to parties other than the party holding the PHI.

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Employer-Sponsored Group Health Plan

Employer-sponsored group health plans are an employee welfare benefit plan including insured and self-insured plans to the extent that the plan provides medical care to employees or their dependents.

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Health Care Operations

Health care operations refers to quality assessment and improvement activities, peer review, education and credentialing activities; conducting or arranging for medical review, legal and auditing services, including fraud and abuse detection and compliance programs; and business planning, business management and general administrative activities of the entity.

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Identifiable Information

Information that can be used to reasonably identify members, including health and demographic data, name, address, account numbers, Social Security number, phone number, drivers license numbers, birth date, e-mail address, full face photographic image, or comparable images, and other unique characteristic, identifying numbers, or code.

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Individual

A person who is the subject of PHI. The individual may be an applicant, current or former subscriber, or current of former member.

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Minimum Necessary

The least amount of information necessary to complete the intended purpose of the use or disclosure.

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PHI

An acronym for protected health information. PHI is individually identifiable health information transmitted or maintained in any form. PHI does not include employment records held by a covered entity in its role as employer.

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Payment

Activities such as obtaining premiums, adjudicating claims, making coverage determinations, providing benefits, and obtaining or providing reimbursement.

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Plan Documents

Formal, written legal documents that establish the group health plan.

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Privacy

The information that must remain confidential; who or what entities are permitted access to that information; and for what purposes that information may be used or disclosed.

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Protected Health Information

Information in any form (electronic, paper, verbal, etc.) that is created, received, or maintained by BCBSM or BCN and that identifies the individual (see definition of identifiable information) and relates to the past, present or future physical or mental condition of that individual, or payment for the provision of the individual's health care.

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Receipts

For underwritten groups, receipts means premiums paid during the plan's last full fiscal year. For self-funded groups, receipts means the total amount paid for claims during the last full fiscal year.

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Security

Refers to how PHI is controlled - the physical, technical and administrative safeguards needed to keep it private.

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Summary Plan Descriptions

An SPD contains all of the information with regard to an employer's group health plan, including a description of the benefits provided.

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TPO

An acronym used for treatment, payment or health care operations.

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Treatment

The provisions, coordination, or management of health care by a health care provider.

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