Patient Notification of OASIS Collection and Reporting

2202.9 - Patient Notification of OASIS Collection and Reporting (Rev. 1, 05-21-04) Under existing patient rights regulations (42 CFR 484.10(a) and (d), the HHA must provide the patient with a written notice of the patient’s rights to confidentiality of medical records in advance of furnishing care to the patient. As part of the patient’s rights, the HHA is required to notify the patient of its policies and procedures for disclosure (confidentiality) of clinical records at the time of admission. The HHA must maintain documentation showing that this requirement has been completed; therefore, HHAs must develop admission policies that encourage patient compliance with assessment procedures. Failure to collect and report accurate and complete OASIS data on all applicable patients places the HHA at risk of losing its Medicare certification. States will be able to monitor whether HHAs are submitting the required OASIS information through use of data management reports. While patients have the right to refuse to answer questions posed by the HHA, very few OASIS data items rely solely on direct patient questioning. Therefore, HHAs must complete all OASIS data items as best they can, using their assessment skills. 2202.9A - Informing Patients of OASIS Collection and Reporting (Rev. 1, 05-21-04) On or after July 19, 1999, HHAs were required to provide existing patients with privacy notifications. To properly inform patients of their rights under the Privacy Act, the provider must furnish each patient with information required by the Privacy Act. Under the authority of the Privacy Act, notices must contain the following information: • The right to be informed that OASIS information will be collected and the purpose of collection; • The right to have the information kept confidential and secure; • The right to be informed that OASIS information will not be disclosed except for legitimate purposes allowed by the Federal Privacy Act; • The right to refuse to answer questions; and • The right to see, review, and request changes on their assessment. The statements of patient privacy rights with regard to the OASIS collection (one for Medicare/Medicaid patients, one for all other patients served by the HHA) are available on the OASIS Web site as part of the June 18, 1999, “Federal Register” notice. HHAs must include these statements as part of their admission information. Effective December 8, 2003, HHAs who choose to collect OASIS data on their non-Medicare /non-Medicaid patients must continue to comply with informing patients with privacy notifications. HHAs that do not collect OASIS data on non-Medicare/non-Medicaid patients are no longer required to provide the Privacy Act notification. 2202.9B - Right to See, Review, and Request Changes (Rev. 188, Issued: 04-26-19, Effective: 04-26-19, Implementation: 04-26-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. The “Federal Register” notice of June 18, 1999, requires that, under the Privacy Act, Medicare/Medicaid patients have the right to see, review, and request changes in their assessments. HHAs must accommodate patients (or their representative), who request this review. If the patient disputes OASIS information collected as part of a comprehensive assessment, the HHA has two options; it can agree or disagree with the dispute. 1. The HHA Agrees.--If the HHA agrees with the patient’s request, it accepts the request, and changes the applicable OASIS data item(s) on the assessment. A corrected assessment can be submitted to the State, using the terms of the OASIS correction policy. 2. The HHA Disagrees.--If the HHA disagrees with the patient’s request, the patient should request written documentation that the disputed information will not be changed by the HHA including the reason(s) why. If a patient chooses to pursue his/her request at the Federal level, he/she may contact CMS at 1-800-Medicare, toll free, for further review of the disputed issue. The individual contesting a record will be advised to write to the Privacy Officer, CMS, 7500 Security Boulevard, Baltimore, Maryland, 21244-1850, identify the record, and specify the information being contested. This correspondence must include the HHA’s written documentation refusing the change. It must also state the corrective action sought and the reasons for the correction with supporting justification. (These procedures are in accordance with the Department’s regulations (45 CFR 5b.7.) To preserve the privacy of the OASIS/HHA system of records, the Privacy Act Privacy Officer may require that the individual provide the following information for verification purposes: The system name, Medicare beneficiary identifier, and, for verification purposes, the individual’s name (woman’s maiden name, if applicable), social security number, address, date of birth, and sex. (Furnishing the social security number is voluntary, but it may make searching for a record easier and prevent delay.) This information must be notarized to preserve the confidentiality of this process. The HHA Medicare/Medicaid patient who wants to know if there is a record belonging to him/her in the OASIS/HHA system of records, or wants to review the record contained in the CMS OASIS/HHA system of records repository would follow the same process. The patient can contact CMS toll free at 1-800-Medicare to get instructions for how to pursue his/her request.