Notice of Insurance Information for Individual Plans
We are providing this notice to you to help you understand how we may collect information about you, the type of information that may be collected, and what information may be disclosed about you to the Plan’s affiliates and to non-affiliated third parties. If you have any questions about any of the information or terms used in this notice please contact Optima Health in writing at:
Optima Health Compliance Department
4417 Corporation Lane
Virginia Beach, VA 23462
What We Mean By Personal, Privileged, Medical Record, And Financial Information
"Personal Information" means any individually identifiable information gathered in connection with an insurance transaction from which judgments can be made about an individual's character, habits, avocations, finances, occupation, general reputation, credit, health, or any other personal characteristics. "Personal information" includes an individual's name and address and medical-record information, but does not include (i) privileged information or (ii) any information that is publicly available.
"Privileged Information” means any individually identifiable information that (i) relates to a claim for insurance benefits or a civil or criminal proceeding involving an individual, and (ii) is collected in connection with or in reasonable anticipation of a claim for insurance benefits or civil or criminal proceeding involving an individual.
"Medical-record Information” means personal information that:
- Relates to an individual's physical or mental condition, medical history, or medical treatment; and
- Is obtained from a medical professional or medical-care institution, from the individual or from the individual's spouse, parent, or legal guardian.
"Financial Information" means personal information other than medical record information or records of payment for the provision of health care to an individual.
“You” and “Your” means the primary applicant, also known and identified in our application and/or our policy as policyholder, subscriber and/or member.
“We”, “Our”, or “Us” means Optima Health. Optima Health is the trade name of Optima Health Plan, Optima Health Insurance Company, Optima Health Group, Inc., and Sentara Health Plans, Inc.
“Investigative consumer report" means a consumer report or a portion thereof in which information about a natural person's character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with the person's neighbors, friends, associates, acquaintances, or others who may have knowledge concerning such items of information.
"Consumer reporting agency" means any person who:
- Regularly engages, in whole or in part, in the practice of assembling or preparing consumer reports for a monetary fee;
- Obtains information primarily from sources other than insurance institutions; and
- Furnishes consumer reports to other persons.
"Affiliate" or "affiliated" means a person that directly, or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with another person.
"Nonaffiliated third party" means any person who is not an affiliate of an insurance institution but does not mean (i) an agent who is selling or servicing a product on behalf of the insurance institution or (ii) a person who is employed jointly by the insurance institution and the company that is not an affiliate.
Why We Collect Information About You
Optima Health needs to know general information about you, such as your name and the names of your dependents, your address, your age, your marital status, and other more specific medical information for business purposes, including, but not limited to, processing claims, evaluating eligibility for covered services, administering health benefit plans, educational programs, disease management programs, and other transactions related to your health care services.
We may collect and use certain financial information about you such as name, birth date, mailing address, employment, social security number, marital status, and checking account information. We need this type of information to administer your health benefits, process claims and/or premium payments and collections, market products, and/or as part of our enrollment process.
We get most of this information directly from you on your application or other enrollment forms. We may also get information about you and your dependents from other public information sources. When you complete and sign your application for coverage, you authorize any physician, hospital, pharmacy, pharmacy benefit manager, or any other provider of health services or supplies, any insurance company, or other organization, institution or person that has any records or knowledge of your health or the health of your dependents to give to Optima Health any such information for the purpose of determining eligibility for coverage, for claims processing and payment, .and for coordination of medical benefits.
If you receive insurance coverage from an employer group plan we may also receive information about you from your employer, or from your or your employer's insurance broker. If you receive insurance coverage through a governmental program, from local, state or federal agencies or their representatives we may receive information about you from those programs. In some instances, we may receive coverage information about you from another insurance carrier with which you have insurance (this is done to coordinate payment of your medical bills.)
Investigative Consumer Reports
We may obtain information, either directly or through an investigative consumer report, by means of interviews with your neighbors, friends, or others with whom you are acquainted. This inquiry includes information about your character, general reputation, personal characteristics, and mode of living. You may ask to be interviewed in connection with the preparation of the investigative consumer report. If you request, we will provide you with any reasonable procedure for such a personal interview to be conducted. If Optima Health uses an insurance support organization as our facilitator, we will inform them of your request for an interview. You are entitled to receive a copy of the investigative consumer report upon request.
How We Protect Your Information
We treat your information in a confidential manner. We restrict access to nonpublic personal and financial information about you to those employees and other persons hired by us who need to know the information to provide services to you. Our employees are required to protect the confidentiality of your information. We maintain physical, electronic and procedural safeguards that comply with applicable laws and regulations to store and secure information about you from unauthorized access, alteration and destruction.
We may enter into agreements with other companies to provide services to us to make services available to you. Under these agreements, the companies must safeguard information about you and they may not use it for purposes other than helping us to improve our service to you.
How We Disclose Personal, Privileged, Medical and Financial Information
To administer your health coverage we may need to disclose information about you. According to law we may disclose information about an individual collected or received in connection with an insurance transaction, without written authorization, if the disclosure is:
- To insurers, agents, or insurance support organizations. Data must be reasonably needed for them or us: (a) to detect or prevent a crime, fraud or material misrepresentation or nondisclosure; or (b) to perform our or their function relating to your insurance such as determining an individual's eligibility for benefits or payment of claims.
- To a medical care institution or medical professional for the purpose of: (a) verifying insurance coverage or benefits; or (b) informing you of a medical problem of which you may not be aware; or (c) conducting an operations or services audit.
- To a state or federal insurance regulatory authority.
- To a law enforcement authority or other government authority to prevent or prosecute fraud or other unlawful activities.
- In response to facially valid administrative or judicial order, including a search warrant or subpoena.
- To those engaged in actuarial or research studies, provided: (a) no names will be used in their report; (b) all data is destroyed or returned to us after use; and (c) no data will be disclosed unless it is authorized by law.
- To a nonaffiliated third party whose only use of such information will be in connection with the marketing of a nonfinancial product or service, provided: (a) no medical-record information, privileged information, or personal information relating to an individual's character, personal habits, mode of living, or general reputation is disclosed, and no classification derived from the information is disclosed (b) the individual has been given the opportunity to indicate that he or she does not want financial information disclosed for marketing purposes and has given no indication that he does not want the information disclosed and (c) the nonaffiliated third party receiving the information agrees not to use it except in connection with the marketing of the product or service.
- To a group policyholder for reporting claims experience or conducting an audit of the insurance institution's or agent's operations or services provided the information disclosed is reasonably necessary for the group policyholder to conduct the review or audit.
- To a government authority in order to determine eligibility for health benefits for which it may be liable.
- To a certificate holder or policyholder for the purpose of providing information regarding the status of an insurance transaction.
- Pursuant to any federal Health Insurance Portability and Accountability Act privacy rules promulgated by the United States Department of Health and Human Services.
- To others as permitted or required by law.
If you do not want information disclosed to affiliates or non-affiliated third parties so that they may tell you about other products or services, you may write to us and tell us not to disclose information for this purpose. Optima Health may make a brief report to the Medical Information Bureau (MIB), a non-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB upon request will supply such company with the information in its file. Optima Health may release information in its file to other insurance companies that you apply for insurance or to which a claim for benefits may be submitted. A consumer reporting agency that prepares a consumer report may keep the information it has gathered and disclose it to others.
Your Right of Access to Information
- If we do not approve your application for coverage, we will tell you and explain the reasons for our decision in writing. You have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of any investigative consumer report we request. You also have the right to request a written summary of your rights as a consumer from the consumer reporting agency that prepared the report. Upon receipt of a request from you, the MIB, or any other consumer reporting agency we use, will arrange disclosure of any information it may have in your file. If you question the accuracy of the information in the MIB file, or your file with any consumer reporting agency that we utilized in connection with your application, you may contact MIB or any specific consumer reporting agency that we used and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. Specific to MIB, their information office is Post Office Box 105, Essex Station, Boston, Massachusetts 02112. Their toll-free telephone number is 866-692-6901 (TTY # 866-346-3642 for the hearing impaired).
- You have the right to request access to data about you in our files. Your request must: (a) be sent to us or our agent; (b) be in writing; (c) clearly describe the data you want; (d) clearly describe the purpose for which you want the data; and (e) be for data which we or our agent can reasonably locate and retrieve.
- We will respond to your request within 30 business days from the date your request is received. Our response will: (a) inform you of the nature and substance of the recorded personal information in writing, by telephone, or by other oral communication; (b) permit you the right to see and copy, in person, the recorded personal information pertaining to you or to obtain a copy of the recorded personal information by mail, whichever you prefer, unless the recorded personal information is in coded form, in which case an accurate translation in plain language shall be provided in writing; and (c) disclose the identity, if recorded, of those persons to whom we have disclosed the personal information within two years prior to the request, and if the identity is not recorded, the names of those insurance institutions, agents, insurance-support organizations or other persons to whom such information is normally disclosed; (d) give you the rights, as described below, regarding correction, amendment, or deletion of recorded personal information.
- Medical Record Information supplied by a medical care institution or medical professional and requested by you, together with the identity of the medical professional or medical care institution that provided the information, will be provided to the medical professional designated by you and licensed to provide medical care with respect to the condition to which the information relates. We will notify you, at the time of disclosure, that we have provided the information to the medical professional.
- We may charge a reasonable fee for providing copies of data in our files.
Your Rights Regarding Correction, Amendment or Deletion of Information in our Files
- If you feel data about you in our files is wrong, you can request correction, amendment or deletion. You must make your request in writing.
- We will have 30 business days from receipt of your request to respond. Our response will either: (a) confirm that we have made the changes you asked for; or (b) inform you of our refusal to change our records.
- If we correct, amend or delete recorded personal information about you we will notify you in writing and furnish the corrections, amendment, or fact of deletion to: (a) any person specifically designated by you who, within the preceding two years, may have received the recorded personal information; (b) any insurance-support organization whose primary source of personal information is insurance institutions if the insurance-support organization has systematically received the recorded personal information from the insurance institution within the preceding seven years. The correction, amendment, or fact of deletion need not be furnished if the insurance-support organization no longer maintains recorded personal information about the individual; and (c) any insurance-support organization that furnished the personal information that has been corrected, amended or deleted.
- If we refuse to change our records, you can send us a written statement for our files. In it, you can state: (a) what you think is the correct, relevant or fair information; and/or (b) why you disagree with our refusal. If you send us such a statement, we will (a) keep it with your file so that it will be seen by any-one reviewing the file; (b) include it with any data sent to others about you; and (c) send it to anyone described in subsection 3, above.
- The above rights do not extend to data connected with or in preparation for a claim or civil or criminal proceeding involving you.
Whom You Should Contact If You Have Additional Questions About this Notice
If you have any questions or comments concerning this Notice, please contact the health plan by mail at:
Optima Health Compliance Department
4417 Corporation Lane
Virginia Beach, VA 23462