Release for Title XVIII Claims Information for Complementary

80.1 - Release for Title XVIII Claims Information for Complementary Insurance Purposes (Contractors) (Rev. 1, 09-11-02) The contractor may not release or use information obtained in the administration of the Medicare program for non-program activities. However, when the beneficiary has given written authorization the contractor is permitted to release certain information to its complementary insurance program under specific conditions in its capacity as insurance writer or administrator, or to other insurers for complementary health benefits purposes. Under no circumstances may the contractor use the knowledge of an individual's entitlement or benefit utilization information for purposes of dropping an individual from a group health insurance plan. A. Information That May be Released Subject to necessary authorizations, copies, extracts, or summaries of only the following records may be released: • Provider billing forms (e.g., Form CMS-1450); • Explanation of benefits for Part B Provider Services, or denial letters; and • Information on date of entitlement to Part A, or date of enrollment under Part B, or the date Part B coverage began. Requests for other information desired for complementary insurance purposes should be referred to the RO. B. Form of Authorization The contractor must make certain that information is not released without the required authorization. This authorization may be either indicated on the billing and admission form or on a dated statement from the beneficiary. Where the authorization is on a dated statement it must: • Authorize release of information about his/her title XVIII Medicare claim; • Designate to whom the release is authorized; • Show that the release authorized is for complementary insurance purposes (this may be implied by the designation in the second bullet above); • Indicate whether the authorization is for a one-time or ongoing release of data (i.e., for the duration of the claims and appeals process, but not to exceed 2 years); and • Bear the signature of the beneficiary, the beneficiary's legal guardian, or the beneficiary's authorized representative. Where the bill contains a beneficiary signature or indicates that the beneficiary's signature authorizing release of information is contained in the provider's records, the bill must contain the name of the complementary insurer unless a dated statement as outlined above is already on file. Where the contractor has a dated statement on file, information may not be released for individual claims when the beneficiary indicated that they do not want disclosure on that claim. This may be indicated on certain claims forms by the beneficiary checking an appropriate block, or by attaching a separate statement. If someone other than the beneficiary, legal guardian, or authorized representative has authorized disclosure to a third party by filling out the appropriate item on the billing form, the contractor may not release the information unless an authorization from the beneficiary is on file. Instead, where feasible, the contractor will inform the beneficiary (or legal guardian or authorized representative) that the signature on the claims form does not constitute a proper authorization for disclosure and that, if the beneficiary desires information to be disclosed to a third party, the beneficiary should send to either the contractor or the third party, a statement authorizing release. (The contractor will indicate the necessary contents of a proper authorization or enclose an appropriate form or statement for use by the proper party in authorizing release.) If invalid authorizations are a frequent problem, the contractor advises third party payers to obtain appropriate ongoing consent statements from enrollees. C. Methods of Handling Requests Where the complementary insurers desire title XVIII information for certain claims only, either the complementary insurer or the beneficiary may request its release. The complementary insurer must furnish the required authorization(s) for release and must pay any charges. (The Medicare program will absorb charges for supplying duplicate MSN's or billing forms to beneficiaries, their authorized representatives, and to social security offices.) In the absence of a standing arrangement, the mere presence of an "authorization' to release and the identification of a complementary insurer on a title XVIII billing form does not constitute a request for the "release" of information. There must be a specific request for the information. The contractor may enter into a standing arrangement with a complementary insurer to provide and charge for title XVIII information, such as MSNs or deductible non-met letters, in every case in which the contractor receives a title XVIII claim which contains the necessary authorizations and identifies the complementary insurer. D. Release of Title XVIII Claims Information for Complementary Insurance Purposes by Providers Contractors should be aware that, subject to specific written beneficiary authorization, providers are permitted to furnish certain limited information about Medicare eligibility status and related claims information to third party payers for complementary insurance purposes. (See §170.)