CurrentAmbetter GeorgiaPolicy N/A
Privacy Notice — Uses and Disclosures of Protected Health Information (PHI)
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This notice explains how Ambetter Georgia may use, disclose, protect, and allow access to members' protected health information (PHI), and describes member rights and situations when PHI may be used or disclosed without prior authorization. It applies to members of Ambetter Georgia as described in the notice.
Policy Summary
PayerAmbetter Georgia
PolicyPrivacy Notice — Uses and Disclosures of Protected Health Information (PHI)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateSep 8, 2023
Next Review DateN/A
Key ActionObtain written authorization before using or disclosing PHI for sales, most marketing, or psychotherapy notes.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
multipledistinct categories of permitted PHI use/disclosure
6+member privacy rights described
12-monthrepeat-request fee limit
08/09/2023document effective date
Permitted Uses, Disclosures, and Member Rights
Permitted uses and disclosures without authorization
Situations in which Ambetter may use or disclose PHI without member authorization:
Treatment — Use or disclosure of PHI to physicians and other health care providers for treatment purposes, including coordination of care and treatment-related decisions.
Payment — Use or disclosure of PHI for payment activities, including claims processing, coverage determinations, billing, verification of benefits, issuing explanations of benefits, and other payment-related functions (reference internal identifier AMB23-WA-C-00058).
Health care operations & care management — Use or disclosure for care management, quality assessment, provider credentialing, utilization review, program evaluation, customer service, grievance and appeal responses, and other health plan operations; may include sharing with business associates under written agreements.
Public health & safety — Disclosures permitted to public health authorities, the FDA, or other authorities as required for public health, safety, reporting of abuse/neglect, disease surveillance, or to prevent or lessen a serious threat to health or safety.
Fundraising — PHI may be used or disclosed for fundraising communications; members contacted will have the opportunity to opt out of future fundraising contacts.
Research and decision support — Limited disclosures for research review or to determine eligibility or enrollment where permitted by law or regulation and under applicable protections.
Judicial/administrative proceedings — PHI may be disclosed in response to court orders, subpoenas, or other judicial or administrative demands as authorized or required by law.
Organ/tissue donation and deceased matters — Disclosure to coroners, medical examiners, funeral directors, and organ procurement organizations as needed for identification, cause of death determination, or organ/tissue donation.
Emergency/next-of-kin disclosures — Disclosures to family members, caregivers, or others involved in the member's care in emergency situations or when the member is unable to consent, if determined to be in the member’s best interest.
Military, national security, and special governmental functions — PHI disclosures to authorized military authorities, national security, intelligence, or other special government agencies as required.
Situations required or permitted by law — Use or disclosure when required by federal, state, or local law (including compliance with court or law enforcement requests, or other legal processes).
Member PHI rights and procedures
Member rights regarding PHI and how to exercise them.
Access — Members may request access to or a copy of their PHI in a designated record set and may request alternative formats; requests must be made in writing. If access is denied, the member will receive an explanation and information about review rights.
Restriction requests — Members may request restrictions on uses and disclosures of their PHI for treatment, payment, or health care operations and for disclosures to family or friends; the plan is not required to agree but will comply with agreed restrictions except when necessary for emergency treatment.
Confidential communications — Members may request confidential methods or alternative locations for communications of PHI without providing a reason; the plan will accommodate reasonable requests when the alternative means or location can be provided.
Amendment — Members may request amendment of PHI they believe is inaccurate. Requests must be submitted in writing with a reason. The plan may deny requests for specified reasons and will provide an explanation; members may submit a statement of disagreement which will be appended to the record.
Accounting of disclosures — Members may request an accounting of disclosures of their PHI for up to the past 6 years. Repeated requests within a 12‑month period may incur a reasonable, cost‑based fee.
Right to a paper copy of this Notice — Members may request a paper copy of the Notice at any time even if they received it electronically.
Authorizations required — Written authorization is required for disclosures that constitute a sale of PHI, for most marketing communications, and for use/disclosure of psychotherapy notes except in limited circumstances.
Complaints and non‑retaliation — Members may file a written complaint with the plan or with the U.S. Department of Health and Human Services Office for Civil Rights; the plan will not retaliate for filing a complaint.
How to exercise rights — Requests (access, restriction, confidential communications, amendment, accounting, or copies of this Notice) must be made in writing using available forms (privacy forms provided on Ambetter/Coordinated Care website) or by contacting the plan; phone assistance is available at the member privacy contact number.
Contact information — Privacy Official contact details and phone are provided for inquiries and requests (Ambetter from Coordinated Care Corporation; toll‑free 1‑877‑687‑1197, TTY 711).
Referenced Internal Codes
Referenced internal code/identifiermixed
| AMB23-WA-C-00058 | Identifier referenced in payment/claim adjudication examples |
Notices, Authorizations, and Requirements for Providers
Note
Notice updates and authorization for other uses
Ambetter from Coordinated Care may change this Notice and will post revised versions; any uses or disclosures of PHI not described in this Notice will be carried out only with your written authorization.
Prior Authorization
Written authorization required for sale and most marketing
Ambetter requires a written authorization for certain uses and disclosures of PHI, including the sale of PHI and most marketing communications, and other uses specified in the Notice.
- Sale of PHI: Ambetter will require your written authorization before any disclosure that is considered a sale of your PHI.
- Most marketing: Ambetter will require your written authorization to use or disclose PHI for fundraising or most marketing purposes, including certain promotional communications.
Key Terms and Special-Case Disclosures
inv-06: Protected Health Information (PHI)
DefinitionProtected Health Information (PHI): information about a member's health that is protected under HIPAA and described throughout this Notice; Ambetter must maintain the privacy of PHI and provide this Notice explaining uses and protections.
Scope of PHIPHI includes health information in any form (oral, written, electronic) about a member that identifies or could reasonably identify the member.
Organizational obligationAmbetter from Coordinated Care is required by law to protect PHI, follow the terms of the current Notice, and notify members if a breach of unsecured PHI occurs.
Member rights referencedThe Notice describes members' rights to access, amend, and manage PHI (e.g., access copies, request restrictions, request confidential communications).
inv-07: REL and SOGI
REL definedREL refers to race, ethnicity, and language; Ambetter affirms it protects REL information and uses it only as described in the Notice.
SOGI definedSOGI refers to sexual orientation and gender identity; Ambetter affirms it protects SOGI information and limits its use as described in the Notice.
Limited use and protectionsAmbetter will not use REL or SOGI data to determine insurance eligibility, set premium rates, or disclose REL/SOGI to unauthorized individuals; it employs safeguards, staff training, and business-associate requirements to protect these data.
Operational uses permittedREL and SOGI information may be used for program design, provider communication about language needs, and quality assessment when necessary for care delivery and operations as described in the Notice.
inv-08: Special-case disclosures (emergency, prisoner, research)
Emergency disclosuresIn emergencies or when a member lacks capacity, Ambetter may disclose PHI to family, friends, or emergency contacts previously designated or as needed if determined to be in the member's best interest; disclosures are limited to information relevant to care.
Prisoner disclosuresIf a member is an inmate or under lawful custody, Ambetter may disclose PHI to correctional institutions or law-enforcement officials as necessary for the inmate’s health care, safety, or the safety and security of the institution.
Research disclosuresAmbetter may disclose PHI to clinical researchers in certain situations when the research has been approved and privacy-protective safeguards are in place, as permitted by law.
Policy Summary
PayerAmbetter Georgia
PolicyPrivacy Notice — Uses and Disclosures of Protected Health Information (PHI)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateSep 8, 2023
Next Review DateN/A
Key ActionObtain written authorization before using or disclosing PHI for sales, most marketing, or psychotherapy notes.
SourceLink
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