What is HIPAA?

HIPAA is the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). While it is a broad and complicated law, it was essentially 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
  • secure the privacy of patient health information
  • enforce uniform standards for exchanging health information

Additional HIPAA information: 

What does this mean for me?

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

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

Those providers using electronic data interchange (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 Weinberg or via one of our contracted clearinghouses.

If you are interested in submitting electronic health care transactions, please contact us at 1-855-827-2003. 

If you have any questions concerning testing with Fallon Health Weinberg, please contact our EDI Coordinators.

To help you with the EDI process, we have created several Fallon-specific companion guides to the official implementation guides. They are available for download on the EDI companion guides page.

Another important note regarding HIPAA guidelines is that physicians and other health care providers may release protected health information to Fallon Health Weinberg 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.

Fallon Health Weinberg currently contracts with the following clearinghouses:

  1. Change Healthcare (formerly Emdeon and WebMD)
    Call 1-800-845-6592 or
    visit their website at www.changehealthcare.com.
  2. Relay Health (formerly McKesson)
    Call 1-800-735-2963, option 3, or
    visit their website at www.relayhealth.com.