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Guiding Principles

By: Linda Jackson Jones

Helping employees get answers to their personal health benefits questions is a common responsibility for benefit administrators (BAs).

Many employees turn to their company's benefit administrator for assistance because they feel the BA is in a better position to get accurate and timely information from the health insurance carrier. However, there are rules and restrictions that govern how BAs can obtain specific health information for employees.

In the past, BAs could simply ask the health insurance carrier a question related to the personal health of an employee and the carrier could provide the answer directly to the BA. However, this has changed. In today's workplace, there are rules and restrictions for obtaining health information on a specific employee. The federal and state governments have issued strict guidelines with severe penalties concerning the misuse or unauthorized disclosure of an individual's protected health information (PHI).

Therefore, it is important that companies and their designated benefits representative understand these rules and regulations and how they pertain to sharing an employee's PHI.

Getting permission

Benefit administrators can still help employees obtain answers to their personal health questions but they must now follow the guidelines set forth by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HIPAA regulations, effective April 14, 2003, impose specific policies and procedures governing the use and disclosure of an individual's protected health information.

In order to make an inquiry on an employee's behalf, the BA must obtain written consent from the employee. The authorization form is usually specific to the health benefits company to which the inquiry is being made and must contain certain elements required under HIPAA, including the limitations of the authorization, effective and termination dates, and information regarding the individual's rights under the authorization.

Some health benefits companies will only accept an original consent form; others will accept a faxed copy.

Receiving a response

Once the appropriate form is received by the health benefits company, a response to the BA's inquiry can be released. The information that will be reported back to the BA will be the "minimum necessary" - the least amount of information necessary to answer the question, limited to the range of permission.

For example, if the initial inquiry was regarding whether a claim had been processed for payment, the health benefits carrier would provide a response of "no" or a response of "yes" that would include the date of payment. Based on the scope and
wording of the question, what the claim was for and the amount paid may not be disclosed.

If this additional information is needed, it must be addressed in the initial question and would have to be included in the range of permission that the employee granted. HIPAA guidelines are in place to protect each individual's personal health information. The federal and state governments are clear as to what can and cannot be shared without authorization and may impose civil and monetary fines and penalties for noncompliance.

However, these regulations do not mean that BAs cannot help employees receive answers to their personal health questions. Understanding HIPAA guidelines and your health benefit company's policies regarding authorization forms will allow your BA to continue to help employees find out answers to important health benefit questions.

For more information on HIPAA guidelines, visit or review the HIPAA Regulations at the Department of Health and Human Services Web site,

Author Bio
LINDA JACKSON JONES has more than 16 years of experience in the health care industry. She has been with Vista Health Plan Inc. since 1994. As manager of account services for Vista Health Plan, she is responsible for membership growth and retention of small and large employer group. Reach her at

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