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electronic health information management - TXs in which health care info is accessed, processed, stored and transferred electronically
individually identifiable health information - includes address, DOB, physical or mental health, provision of care, or payment for care - IIHI data identify the individual or establish reasonable basis to believe it can be used to ID the person
Office of the Inspector General - safeguards health & wealthfare of Medicare/Medicaid beneficiaries & protect program integrity
policies and procedures (of a provider or insurer), as determined by a privacy officer to comply with HIPAA
protected health information - IIHI in any form: paper, computerized, spoken words, x-ray-films - any info that identifies an individual and describes his/her health status, age, sex, ethnicity, or other demographic characteristics, whereh or not stored or transmitted electronically
privacy officer ore privacy official - employed or contracted by provider to develop/set P & P and train/manage staff to be compliant with HIPAA
meeting regulations, recommendations, and expectations of federal and state regulating agencies
"principles and practices" elements
regulations and recommendations to protect individuals, streamlining of processes, supporting system-wide stability
like a user's manual - standardized process to enable consistent and effective compliance management
HIPAA Title II primary purpose
development & implementation of standardized electronic TXs AND implementation of procedures to ensure privacy and security of individuals' health data
covered entities under HIPAA
transmit info via electronic TXs covered by HIPAA: third-party payers/insurers, providers, and clearinghouses
receive NPP, access and request amendments to health records, receive an accounting of those who have received their health info, request restrictions on who can access their health records
internet, extranet, intranet, phone lines for transmission of data (including FTP and faxes), mag tape, disks, CDs
performs or assists in the performance of a function involving the use of individually identifiable health information, including claims processing or administration.... example: outside billing company
formal, written permission to use/disclose his/her identifiable health info for purposes other than TPO.
breach of confidential communication
unauthorized release of information, a HIPAA violation - breacher is required to mitigate harmful effects of the breach
HIPAA confidentiality exceptions
MCO management audit; highly contagious/infectious communicable disease; malfunction of medical device; patient is suspect in criminal investigation; assist in locating missing person, witness or suspect; subpeona, search warrant; lawsuit; suspicious death; 3rd party bill payer request; "common good"/public health state law as for abuse
medical code sets
data elements used uniformly to document diagnoses (ICD-9-CM) and procedures (CPT, HCPCS)
Current Procedural Terminology - produced by AMA; updated each January 1, Category III (emerging technology) codes also update in July
International Classification of Diseases, 9th revision, clinical model - produced by U.S. DHHS; updated each October 1
HealthCare Common Procedure Coding Sytem - produced by CMS - updated each January 1 w/periodic updates as needed
regulations related to security of ePHI and electronic TXs - 1) admin safeguards/P&P; 2) tech safeguards/protect and control access to electronic info; 3) physical safeguards/prevent unauthorized physical access to computers, buildings
Civil Monetary Penalties law - penalizes a person/org for making false, upcoded or medically unnecessary claims against any federal health care program; fines for noncompliance with privacy/security regulations; hefty fines and years of imprisonment for knowingly obtaining/disclosing IIHI, using it for personal gain
private citizen brings a civil action on behalf of federal govt for a violation of the False Claims Act
STARK I and II
prohibit a provider from referring patients to an entity with which he/she has a financial relationship
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