UVA Health Plan Ombudsman

1. UVA Health Plan Ombudsman Joanne Hayden 924-4346 jrh5y@virginia.edu

2. OVERVIEW • What is an ombudsman? • What is the role of the UVA Health Plan Ombudsman? • Examples/resources • What is the role of the UVA HIPAA Privacy Officer? • Contact information

3. OMBUDSMAN • Aperson (such as a government official or an employee) who investigates complaints and tries to deal with problems fairly.(Merriam Webster dictionary) • The word “Ombudsman” is Swedish and means “representative”. .(Merriam Webster dictionary) • A man who investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers or students and an institution or organization.(the Free Dictionary) • A government official, especially in Scandinavian countries, who investigates citizens' complaints against the government or its functionaries. (the Free Dictionary)

4. The UVa Health Plan Ombudsman will: • Explain the UVa Health Plan policies and benefit coverage. • Provide answers to questions regarding the UVa Health Plan. • Listen to complaints and concerns regarding the UVa Health Plan. • Make UVa Health Plan information available to UVa employees. • Provide information concerning complaint and appeal procedures and advise employees which review level is appropriate. • Investigate payment problems for claims submitted to the UVa Health Plan that employees have been unable to resolve themselves. • Refer issues to other university offices or committees as appropriate.

5. Explain the UVa Health Plan Policies and Benefit Coverage Examples: • Review coverage found in Summary Plan Description and Schedule of benefits • Copays, co-insurance, deductible • Out of network coverage-$$$$ • How to find a provider UVa’s custom docfind • Medical, prescription and dental services covered • Foreign enrollment – 90 days or more

6. Provide Answers to Questions regarding the UVA Health Plan Examples: • How a claim processed- preventive or routine. • How long can keep child on plan. • How to get a Specialty medication. • Is a Shingles vaccine covered ? • Urgent care & ER care.

7. Listen to Complaints and Concerns regarding the UVa Health Plan Examples: • High prescription drug copay for brand antibiotic • Denied Physical Therapy • Denied crown for tooth (pay less costly alternative)

8. Make UVa Health Plan Information Available to UVaEmployees Examples: • Telephone /email/appointments • Human Resources Benefits Website • Benefits committee • UVa Health Plan Ombudsman Alias • UVa Health Plan Ombudsman FAQ

9. Provide Information Concerning Complaint & Appeal Procedures & Advise Employees which Review Level is Appropriate Examples: • Call TPA and check status of denial – medical, dental, prescription. • Advise what is needed, e.g. PA request for ADHD medication over 18. • Expedited versus standard review ,e.g. MRI cancer, ER denial .

10. Investigate Payment Problems for Claims Submitted to the UVa Health Plan that Employees Have Been Unable to Resolve Themselves Examples: • Balance billing by anesthesia • Foreign claims • Coordination of Benefits • Benny card suspension

11. Refer Issues to other University Offices or Committees as appropriate Examples: • Develop annual “wish list’ for Plan leadership to consider. • Communicate issues to Plan leadership, e.g complaints about Dependent audit . • Refer to Medical Center Care Connection, PFS, UPG, patient representatives, HIPAA department, Hoo’sWell, DHRM • Refer to UVA EEOC Ombudsman. • Refer to Benefits committee.

12. Confidentiality/HIPAA • All encounters with the UVa Health Plan Ombudsman are treated with confidentiality. Information retained by the UVa Health Plan Ombudsman is kept secure. However, with the verbal or written request of the employee, the Ombudsman may carry such information forward. • The UVA Health Plan is a covered entity under HIPAA. • Ombudsman is the Privacy Officer for the UVA Health Plan.

13. HIPAA Privacy Officer • Oversees HIPAA Privacy Rule compliance, training, policies, document maintenance and retention. • Implements Safeguards. • Responds to inquiries and investigates complaints. • Obtains HIPAA authorizations for adult dependents. • Provides copies of policies and Privacy Notice upon request.

14. UVA Health Plan Ombudsman Resources • UVA Health Plan Ombudsman website http://www.hr.virginia.edu/hr-for-you/university-staff/university-staff-benefits/uva-health-plan-ombudsman/ • Summary Plan Description http://www.hr.virginia.edu/uploads/documents/media/Univ_of_UVA_SPD_Final_2-13-2012.pdf • Benefits website http://www.hr.virginia.edu/ • Schedule of benefits, docfind , Beginning right maternity program, prescription cost savings, TPA websites • Email alias: healthplanombuds@virginia.edu

15. Questions /Thank you!