HIPAA is the federal Health Insurance Portability and Accountability Act of 1996. It is a broad and complicated law that was created to:

  • Protect patients' access to health care coverage when they change jobs
  • Allow women to receive coverage for reconstructive surgery after a mastectomy
  • Provide mothers and newborns at least 48 hours in the hospital after delivery
  • Enforce uniform standards for exchanging health information

In addition, it gave the Department of Health and Human Services the authority to mandate the use of certain standards and to specify the types of measures required to protect the privacy and security of personally identifiable health care information.
Additional HIPAA information:

What does this mean for me?

As a Summit ElderCare participant, what do I need to know about HIPAA?

The HIPAA requirements are there to protect you, the consumer. With respect to health care, HIPAA is meant to simplify communications between health plans and providers—mostly through electronic means. However, you should be aware that HIPAA outlines strict guidelines to ensure the privacy and confidentiality of your PHI (protected health information, such as your name and medical information). These guidelines require that your PHI be used for purposes of treatment, payment and health plan operations, and not for purposes unrelated to health care.

Under HIPAA, Summit ElderCare must:

  • Provide a Notice of Privacy Practices to all members
  • Make sure that every person or company who works with us protects member information as we do.
  • Carry out privacy training for all employees, whether they deal with member records or not.
  • Have consequences in place if member information is used or shared improperly.

As a family member or caregiver, how does HIPAA affect my relationship with Summit ElderCare?

In order to provide a complete care package to our participants, Summit ElderCare works closely with caregivers and family members. However, under HIPAA, Summit ElderCare must ensure that only the participant and those with the proper authority are given access to the participant’s personal health information. Therefore, in addition to obtaining any forms of legal authorization for a participant (such as health care proxy or durable power of attorney), Summit ElderCare requests that the participant designate one or more persons to act as his or her personal representative(s). A personal representative is an individual who may be involved in the participant’s health care, but may not be otherwise expressly authorized to act on the participant’s behalf. Participants may designate one or more personal representatives using one of Fallon Health's forms, below. If you have questions about who may assist your loved one with their care, please contact Summit ElderCare at 1-877-837-9009 (TRS 711).

As a physician or provider, what do I need to know about HIPAA and Fallon Health?

A key HIPAA compliance issue for physicians and other health care providers is the use of electronic transactions.

Those providers using electronic data interchange, or EDI, must use standard transactions, such as the 837 for claims. Fallon Health must accept standard transactions, and offers two methods of EDI for this: direct through Fallon Health or our contracted clearinghouses (currently not available for sending hospital claims).

If you are interested in submitting electronic health care transactions, please contact Fallon Health at 1-866-ASK-FCHP, option 6, or email us to request to become a trading partner. Click here to start the enrollment process.

If you have any questions concerning testing with Fallon Health, please contact our EDI Coordinators at 1-866-ASK-FCHP, option 6.
To help you with the EDI process, we have created several Fallon Health-specific companion guides to the official implementation guides. They are available for download on the Electronic data submission page.

Another important note regarding the new HIPAA guidelines is that physicians and other health care providers may release protected health information to Fallon Health for payment and health care operations purposes.

For more information about HIPAA requirements for physicians and providers, visit the American Medical Association's HIPAA resource page.

This page was last updated on April 28, 2022.