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Notice of Privacy Practices

Effective 4/14/03

Revised 7/22/2021

This Notice Describes How Health Information About You May Be Used and Disclosed and How You Can Get Access To This Information. Please Review It Carefully.

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) allows covered entities under common ownership or control to join together to form a “single affiliated covered entity” for purposes of compliance with HIPAA. The following organizations form the Delta Dental Affiliated Covered Entity (“Delta Dental ACE”) and are covered by this notice:

Delta Dental of Iowa

Veratrus Benefit Solutions, Inc.

Delta Dental ACE may be referred to in this notice as “us,” “our” or “we.”


All correspondence relating to the contents of this notice should be directed to the following contact: Delta Dental ACE Privacy Official, PO Box 9010, Johnston, IA 50131-9010.

Who Will Follow This Notice
This notice describes our health information practices and that of any third party that receives health information from or for us to assist us in providing your benefits.

Our Pledge Regarding Health Information
We understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the claims submitted for payment under your dental and/or vision benefits plan. This notice applies to all of the health records we maintain. Your provider may have different policies or notices regarding the provider’s use and disclosure of your health information created in the provider’s office.

HIPAA imposes numerous requirements on how certain individually identifiable health information – known as protected health information or PHI – may be used and disclosed. This notice is required by HIPAA and will  describe how we and any third party that receives health information from or for us to assist us in providing your dental and/or vision benefits may use and disclose health information about you. This notice also describes our obligations and your rights regarding the use, access,  and disclosure of your health information.

We are required by law to abide by the terms of this notice to:

  • make sure that health information that identifies you is kept private;
  • give you this notice of our legal duties and privacy practices with respect to health information about you; and
  • follow the terms of the notice that is currently in effect.

We are also required to provide notice to you of a breach of your unsecured protected health information.

How We May Use and Disclose Health Information About You
The following categories describe different ways that we use and disclose health information, as permitted by federal and state law.  HIPAA generally permits use and disclosure of your health information without your permission for purposes of health care treatment, payment activities, and health care operations. These uses and disclosures are more fully described below. Please note that this notice does not list every use or disclosure; instead it gives examples of the  most common uses and disclosures.

For Treatment: We may use or disclose health information about you to facilitate treatment or services by providers. For example, we might disclose information about you with the provider who is treating you.

For Payment (as described in applicable regulations). We may use and disclose health information about you to determine eligibility for benefits, to facilitate payment for the treatment and services you receive from providers, to determine coverage under your dental and/or vision plan, or to coordinate coverage. For example, we may tell your provider about treatments you have received so we can pay you or your provider for covered services. We may use information about a treatment you are going to receive in order to provide prior approval or to determine whether your dental and/or vision plan will cover the treatment. Likewise, we may share health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments.

For Health Care Operations (as described in applicable regulations). We may use and disclose health information about you for health care operations. These uses and disclosures are necessary to provide quality care to all subscribers and covered beneficiaries. For example, we may use health information in connection with: conducting quality assessment and improvement activities; underwriting, premium rating, internal grievance resolution, and other activities relating to coverage; conducting or arranging for dental and/or vision care review, legal services, audit services, and fraud and abuse detection programs; creating de-identified health information or limited data sets; business planning and development such as cost management; and business management and general administrative activities, such as customer service, management activities related to privacy compliance, and providing data analysis for policyholders, plan sponsors or other customers, provided that health information identifying you will not be disclosed in or with such data analyses.

NOTE: We will not use or disclose genetic information for underwriting purposes.

OTHER PERMITTED USES AND DISCLOSURES

To Comply with Federal and State Requirements. We will disclose health information about you when required to do so by federal, state or local law. For example, we may disclose health information when required by government agencies that regulate us; to federal, state, and local law enforcement officials; in response to a judicial order,  subpoena, or other lawful process; and to address matters of public interest as required or permitted by law (for example, reporting child abuse and neglect, threats to public health and safety, and for national security reasons). We are required to disclose health information about you to the Secretary of the U.S. Department of Health and Human Services if the Secretary is investigating or determining compliance with HIPAA, or to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law. We may also disclose your health information to a  health oversight agency for activities authorized by law (such as audits, investigations, inspections, and licensure).

To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, we may disclose health information about you in a proceeding regarding the licensure of a provider.

Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Disclosures to Others Involved in Your Care. We may disclose your health information to a family member, friend or any other person you identify, provided the information is directly relevant to that person’s involvement with your care or payment for that care. For example, if a family member or caregiver calls us with prior knowledge of a claim and asks us to help verify the status of a claim, we may agree to help them confirm whether or not the claim has been received and paid. We may also use or disclose your name, location, and general condition, or assist in the identification, location and notification of a person involved in your care.

Business Associates. We may disclose your health information to our business associates. We have contracted with entities (defined as “business associates” under HIPAA) to help us administer your benefits. We will enter into contracts with these entities requiring them to only use and disclose your health information as we are permitted to do so under HIPAA.

Other Uses. If you are an organ donor, we may release your health information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.  We may release your health information to a coroner or medical examiner. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official.

Disclosures to Your Employer or Group Health Plan Sponsor. We will not disclose your personal health information to your employer or group health plan sponsor unless they have elected to sign a confidentiality agreement.  We may disclose summary health information about members in your group health plan to the plan sponsor to use to obtain premium bids for the dental and/or vision insurance coverage offered through your group health plan, or to decide whether to modify, amend or terminate your group health plan.  The summary information we may disclose summarizes claims history, claims expenses, or types of claims experience by the members in your group health plan. 

Uses and disclosures of health information not covered by this notice or applicable law will be made only with your written authorization.  Uses and disclosure of protected health information for marketing purposes and disclosures that constitute sale of protected health information require your written permission.  If you provide us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization.  However, we are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.

Your Rights Regarding Health Information About You
You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your plan benefits. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Delta Dental ACE Privacy Official at the address provided on the first page of this notice. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed.

Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Delta Dental ACE.

To request an amendment, your request must be made in writing and submitted to the Delta Dental ACE Privacy Official at the address provided on the first page of this notice. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

  • is not part of the health information kept by or for us;
  • was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • is not part of the information which you would be permitted to inspect and copy; or
  • is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures" (that is, a list of certain disclosures we have made of your health information) when such disclosure was made for purposes other than treatment, payment, or health care operations, as authorized by you, or for certain other activities, for up to six years after the record is created.

To request an accounting of disclosures, you must submit your request in writing to the Delta Dental ACE Privacy Official at the address provided on the first page of this notice. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request if the use or disclosure of health information is consistent with this notice.

To request restrictions, you must make your request in writing to the Delta Dental ACE Privacy Official at the address provided on the first page of this notice. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).

Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Delta Dental ACE Privacy Official at the address provided on the first page of this notice. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a copy of this notice at our website, www.deltadentalia.com.

To obtain a paper copy of this notice, contact the Delta Dental ACE Privacy Official at the address provided on the first page of this notice.

Breach Notification. In the event of a breach of your unsecured health information, we will provide you notification of such a breach as required by law.

Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our website. The notice will contain on the first page, in the top right-hand corner, the effective date.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with Delta Dental ACE or with the Secretary of the United States Department of Health and Human Services. To file a complaint with Delta Dental ACE, contact the Delta Dental ACE Privacy Official at the address provided on the first page of this notice. All complaints must be submitted in writing.

You will not be penalized for filing a complaint