UVA Health Plan Ombudsman
Joanne Hayden 924-4346 [email protected] UVA Health Plan
Ombudsman 11OVERVIEWWhat is an ombudsman?What is the role of the
UVA Health Plan Ombudsman?Examples/resourcesWhat is the role of the
UVA HIPAA Privacy Officer?Contact information
22OMBUDSMAN
A person (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)
33The 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.
44
Explain the UVa Health Plan Policies and Benefit
CoverageExamples:Review coverage found in Summary Plan Description
and Schedule of benefits Copays, co-insurance, deductibleOut of
network coverage-$$$$How to find a provider UVas custom docfind
Medical, prescription and dental services covered Foreign
enrollment 90 days or more
55
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.
66
Listen to Complaints and Concerns regarding the UVa Health
PlanExamples:High prescription drug copay for brand antibiotic
Denied Physical Therapy Denied crown for tooth (pay less costly
alternative)
77Make UVa Health Plan Information Available to UVa
EmployeesExamples: Telephone /email/appointmentsHuman Resources
Benefits WebsiteBenefits committeeUVa Health Plan Ombudsman Alias
UVa Health Plan Ombudsman FAQ
88Provide Information Concerning Complaint & Appeal
Procedures & Advise Employees which Review Level is
AppropriateExamples: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 .
99
Investigate Payment Problems for Claims Submitted to the UVa
Health Plan that Employees Have Been Unable to Resolve Themselves
Examples: Balance billing by anesthesiaForeign claimsCoordination
of BenefitsBenny card suspension
1010
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, HoosWell,
DHRMRefer to UVA EEOC Ombudsman. Refer to Benefits committee.
1111Confidentiality/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.
1212HIPAA 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.
1313UVA Health Plan Ombudsman ResourcesUVA 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: [email protected]
1414Questions /Thank you!
1515
