Billing – Claim Submission

The only exception to a provider’s requirement to submit claims is HIPAA rule 164.522(a)(1)(vi). If a member requests that a provider restrict disclosure of Protected Health Information (PHI) to the health plan AND pays the provider in full, the request must be honored. The request is only applicable for those services/items specifically directed by the member and paid in full.  

This does not apply to PHI required to be disclosed due to federal or state mandates and laws. For more information see the following: Federal Register January 25, 2013 – Final Rule.