Notice of privacy practices

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

Effective: Feb. 16, 2016

Our responsibilities

Sharp Health Plan provides health care coverage to you. We receive information about you when you become eligible and enroll in our health plan. We understand that information about you and your health is confidential. We are committed to protecting the privacy of this information. Federal and California laws make us responsible for protecting the privacy of your health information. This Notice explains your privacy rights regarding Protected Health Information (“Health Information”) and outlines Sharp HealthCare's (“Sharp's”) responsibilities for using and disclosing it. We must provide you with this Notice of Privacy Practices and follow the terms of the Notice currently in effect. We will notify you if a breach of your Health Information occurs, and we will not share your Health Information without your written permission, except as described below.

Changes to this Notice: We have the right to change the privacy practices described in this Notice. If we do make changes, the new Notice will be available upon request, in our office, and on our website at sharphealthplan.com/privacy-practices.

How we may use and disclose your health information

As a health plan, we perform activities such as verifying eligibility and enrollment, approving and paying for health care services, investigating fraud, evaluating the quality of care that you receive, and coordinating your benefits. Federal and California law permits disclosures of your Health Information without any verbal or written permission from you. The following categories describe different ways that we typically use or share your Health Information.

How we use your contact information

We use your contact information to help manage your care and coverage. This may include:

• Providing authorization for care
• Updating you about your care or care options
• Working with you on payment arrangement

We may use automated calls or prerecorded messages when contacting you.

Treatment: We may share your Health Information with health care providers to help you receive the care you need. You may need medical treatment that requires us to approve care in advance. For example, when you require medical treatment that needs preauthorization, we provide information to doctors, hospitals, or other providers so they can deliver appropriate care.

Payment: We use and disclose Health Information to review, approve, process and pay health care claims sent to us for your medical care. For example, Health Information may be shared with the doctors, clinics, or others who submit claims to us for payment. We may also forward Health Information to other health plans or organizations when necessary for payment.

Health Care Operations: We may use information in your health plan record to assess the quality of the health care you receive. For example, Health Information may be used in audits, fraud, waste and abuse programs, care coordination, planning, and other administrative activities. Sharp Health Plan does not use or disclose genetic information for underwriting purposes.

Business Associates: We may disclose your Health Information to our contractors so that they can assist us in providing care and services. To protect your Health Information, we require these business associates to sign a written agreement to safeguard your Health Information.

Telecommunications Relay Services (TRS): TRS may be used to facilitate phone calls for individuals who are deaf, hard of hearing, deaf-blind or have a speech disability. TRS facilitates such calls by using a communications assistant who interprets conversations.

Use of Artificial Intelligence: We may use artificial intelligence (AI) tools to help with various health care and operational tasks to the extent permitted by law. These tools may be provided by our business associates and are typically used to help analyze health data and streamline administrative tasks.

Improving Our Services:We may use information about you, if the law allows it, to help us improve our services or develop new ones. For example, we may use patterns in health plan records to give clinicians better tools to support their decisions.

How else can we use or share your health information?

We are allowed or required to share your information in other ways — usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may share your Health Information in response to a court or an order from an administrative agency. We may also share your Health Information in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute.

Substance use disorder (SUD) records have extra protections. They can only be used or shared for these purposes after you are given notice and a chance to be heard. A court order that allows the use or sharing of SUD records must also include a subpoena or similar legal mandate that requires the records to be disclosed before they can be used or shared.

Appeals of Health Care Decisions: You or your health care providers may appeal decisions about your health care claims. Your Health Information may be used during these appeal processes.

Legal Requirements: We will disclose Health Information about you without your permission when required to do so by law. We can use or share Health Information about you:

• For workers' compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security and presidential protective services

Emergency Situations: We will disclose information about you (including substance use disorder information) as needed to respond to declared emergencies, natural disasters, serious disruptions to treatment facilities and services, and medical emergencies.

Employer Disclosures: We provide employers with only the Health Information allowed by law, such as summary data, premium information, and enrollment details.

Situations requiring your written authorization

If we ever need to use and disclose your Health Information for any reason not described in this Notice, we will first obtain your written permission. If you give us this permission, you may take it back at any time by telling us in writing. Please understand that we cannot take back any disclosures we have already made with your permission. Examples of disclosures that require your authorization include:

Substance Use Disorder Records: We maintain additional protections for Health Information related to substance use disorder (SUD) diagnosis, treatment, or referral for treatment as required by law. These records are kept confidential and cannot be disclosed without your written consent, except in limited situations allowed by law, such as a medical emergency or when required for specific health plan operations. You can give one consent for all future uses or disclosures of your SUD information for treatment, payment, and health care operations. This means that once you provide the consent, your SUD records can be used and disclosed without asking you again as permitted by law, unless you revoke your consent in writing.

Potential for Redisclosure: Health Information disclosed under this Notice or under your authorization may be redisclosed by the recipient and may lose protection under the privacy laws.

Your rights regarding your health information

Important: Sharp Health Plan does not maintain copies of your medical records. If you would like to access, obtain copies, or request changes to your medical records, please contact your doctor, medical group, or clinic directly.

You may contact Customer Care at 800-359-2002 to obtain additional information and instructions for exercising the following rights:

Right to Inspect and Copy: You can request an electronic or paper copy or a summary/explanation of your health plan records. We will provide a copy or a summary of your Health Information within 15 business days of your request. We may charge a reasonable, cost-based fee.

Right to Request Restrictions: You can ask us not to use or share your Health Information in the ways described in this notice. While we will consider all requests, we may not be able to agree to your restriction. If you pay for a service or a health care item out-of-pocket in full, you can ask your provider not to share that information with us or with other health insurers.

Right to Request Confidential Communications: You can ask us to communicate with you in a specific way (for example, using a home phone or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests and will not ask you the reason for your request.

Right to Amend: You may request a correction to your Health Information that you think is incorrect or incomplete. We may deny your request if:

• The information is not created or kept by Sharp Health Plan, or
• We believe it is correct and complete.

If your request is denied, you may ask for a review of our decision. You may also submit a written statement saying why you disagree with our records, and that statement will be kept with your records.

Right to an Accounting of Disclosures: You can ask for a list (accounting) of the times we've shared your Health Information, who we shared it with, and why. The accounting will be provided for three (3) years prior to the date of the request for electronic records, and six (6) years prior to the date of request for non-electronic records. We will not include disclosures for treatment, payment, health care operations, and certain other permitted disclosures. We will provide one accounting per year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months.

Disclosures of substance use disorder (SUD) records made for treatment, payment and health care operations will be included in an accounting of disclosures for electronic records only.

Right to a Copy of This Notice: You have a right to request a copy of this Notice of Privacy Practices. You also can find this Notice on our website at: sharphealthplan.com/privacy-practices.

Complaints regarding your privacy rights

If you believe that we have not protected your privacy and you wish to file a complaint (also called a grievance), you may contact any of the following without fear of retaliation:

Sharp HealthCare

• Mail: Privacy Officer, 8695 Spectrum Center Blvd, San Diego, CA 92123
• Phone: Call us at 858-499-3138
• Email: privacy@sharp.com

U.S. Department of Health and Human Services, Office for Civil Rights (OCR)

• Mail: Office for Civil Rights, U.S. Department of Health & Human Services
  200 Independence Avenue, S.W., Washington, D.C. 20201
• Phone: 1-877-696-6775
• Online: www.hhs.gov/ocr/privacy/hipaa/complaints/

Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.

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