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1.    Navigating HIPAA and PHI
2.    Reference Room: FDA Approvals and TRICARE
3.    Adjunctive vs. Non-adjunctive Dental Care: What's the Difference?
4.    Questions South Region Providers Are Asking
5.    Medication Evaluation Recommended for Major Depression
6.    Contacts 
       
  Navigating HIPAA and PHI  (Article 1) 
  Providers have asked what types of protected health information (PHI) they should and shouldn’t share with Humana Military. As a TRICARE regional contractor, Humana Military requires beneficiaries’ PHI for a variety of purposes, including medical necessity review, case management, claims review, etc. Here are answers to commonly asked questions about PHI.

What information is considered to be protected health information under HIPAA?
PHI is information that is created and obtained as you deliver services to beneficiaries. PHI may include documentation of symptoms, examination and test results, diagnoses and treatments. Certain personal information is also considered to be PHI under the Health Insurance Portability and Insurance Accountability Act (HIPAA), including, but not limited to:
 
  • Home address
  • Home telephone number
  • Race
  • Social Security number
  • Medical records
  • Photographs
  • Any information that may compromise the privacy of or prove harmful to the beneficiary 
  Do I need a patient’s written authorization to send a copy of the patient’s medical record to a specialist or other health care provider who will treat the patient?
No. Providers may disclose PHI to another health care provider for treatment purposes.

If a patient is a minor or is not competent to make health care decisions, may I release information to the parent or guardian?
Providers may not release minors’ information to parents or guardians without a minor’s consent when the services are related to alcoholism, abortion, drug abuse, behavioral health, venereal disease or HIV. If the patient is incompetent, whether a minor or not, the guardian or other person authorized to act on the patient’s behalf may give the consent.

May I release patient information to Humana Military, TMA or healthcare insurance companies for payment purposes?
Yes. Providers are permitted to disclose PHI as necessary to obtain payment for health care. However, the Privacy Rule requires providers to reasonably limit the amount of information disclosed for such purposes to the minimum necessary.

Are the following types of insurance covered under HIPAA: long/short-term disability, workers’ compensation, and automobile liability that includes coverage for medical payments?
No, the listed types of policies are not health plans as defined by HIPAA. HIPAA specifically excludes any policy, plan or program that provides for or pays for benefits other than health benefits or that are secondary or incidental to other insurance benefits. Therefore, providers are not required to release PHI to these plans or programs.

TRICARE offers training in HIPAA compliance. For more information about PHI and other HIPAA issues, visit www.tricare.osd.mil/HIPAA.
 
     
Reference Room: FDA Approvals and TRICARE (Article 2) 
TRICARE covers only those drugs, devices, treatments and procedures whose safety and efficacy have been established and proven by the Food and Drug Administration (FDA). As a provider, you should be familiar with the process by which the FDA approves new medical therapies. The following is an overview of that process.
  • Drug company or sponsor applies for FDA approval of a specific drug, device, treatment or procedure. Before applying for approval, the company/sponsor conducts extensive laboratory testing and research (sometimes several years worth), which they then provide to the FDA with the application for approval.
  • FDA reviews data and gives approval for clinical trials. After reviewing the submission, the FDA will determine whether or not the benefits of the new medical therapy outweigh the risks. If so, the FDA will authorize clinical trials and monitor the results to decide whether the trials should continue or not.
  • FDA studies data from clinical trials and determines whether or not the drug, device, treatment or procedure should be made available to the public. Once the FDA has decided that a submission is safe and effective, it will place restrictions on how it is marketed and prescribed. The FDA also will ensure that labeling includes possible risks and side effects.
  • The new medical therapy is proven. Once the FDA gives approval, the drug, device, treatment or procedure is considered proven and will become available to the public. If the FDA feels that the risks outweigh the benefits, it will be rejected and the company/sponsor will receive a complete list of issues that need to be addressed. 
Studying and testing a new drug or treatment before it can be approved for the general public takes 8.5 years on average. The FDA gives “priority” classification, however, to those treatments that offer significant medical advances over existing therapies and tries to limit the process to 10 months from the time the application is submitted.

For the safety of its beneficiaries, TRICARE does not cover drugs, devices, medical treatments or procedures that have not been approved by the FDA or that have been categorized as “experimental/investigational.”

If you are unsure whether or not a drug or treatment is covered by TRICARE, view the TRICARE policy manual or call Humana Military at 1-800-444-5445. For more information about the FDA approval process, visit www.fda.gov. 

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