NRPM: Standards for Privacy of Individually Identifiable Health Information. 12. Rights and procedures for access for inspection and copying. (§ 164.514)

11/03/1999

In § 164.514, we are proposing that, with very limited exceptions, individuals have a right to inspect and copy protected health information about them maintained by a covered health plan or health care provider in a designated record set. Individuals would also have a right of access to protected health information in a designated record set that is maintained by a business partner of a covered plan or provider when such information is not a duplicate of the information held by the plan or provider, including when the business partner is the only holder of the information or when the business partner has materially altered the protected health information that has been provided to it.

In § 164.506(e), we are proposing that covered plans and providers include specific terms in their contract with each business partner. One of the required terms would be that the business partner must provide for inspection and copying of protected health information as provided in this section. Because our authority is limited by HIPAA to the covered entities, we must rely upon covered plans and providers to ensure that all of the necessary protected health information provided by the individual to the plan or provider is available for inspection and copying. We would require covered plans and providers to provide access to information held in the custody of a business partner when it is different from information maintained by the covered plan or provider. We identified two instances where this seemed appropriate: when the protected health information is only in the custody of a business partner and not in the custody of the covered plan or provider; and when protected health information has been materially altered by a business partner. We are soliciting comment on whether there are other instances where access should be provided to protected health information in the custody of a business partner.

Other than in their capacity as business partners, we are not proposing to require clearinghouses to provide access for inspection and copying. As explained above in section II.C.5, clearinghouses would usually be business partners under this proposed rule and therefore they would be bound by the contract with the covered plan or provider. See proposed §164.506(e). We carefully considered whether to require clearinghouses to provide access for inspection and copying above and beyond their obligations as a business partner, but determined that the typical clearinghouse activities of translating record formats and batching transmissions do not involve setting up designated record sets on individuals. Although the data maintained by the clearinghouse is protected health information, it is normally not accessed by individual identifier and an individual’s records could not be found except at great expense. In addition, although clearinghouses process protected health information and discover errors, they do not create the data and make no changes in the original data. They, instead, refer the errors back to the source for correction. Thus, individual access to clearinghouse records provides no new information to the individual but could impose a significant burden on the industry.

We are proposing that covered plans and providers be required to provide access for as long as the entity maintains the protected health information. We considered requiring covered plans and providers to provide access for a specific period or defining a specific retention period. We rejected that approach because many laws and professional standards already designate specific retention periods and we did not want to create unnecessary confusion. In addition, we concluded that individuals should be permitted to have access for as long as the information is maintained by the covered plan or provider. We are soliciting comments on whether we should include a specific duration requirement in this proposed rule.

Proposed § 164.514 would permit denial of inspection and copying under very limited circumstances. The categories of denials would not be mandatory; the entity could always elect to provide all of the requested health information to the individual. For each request by an individual, the entity could provide all of the information requested or it could evaluate the requested information, consider the circumstances surrounding the individual’s request, and make a determination as to whether that request should be granted or denied. We intend to create narrow exceptions to the stated rule of open access and we would expect covered plans and providers to employ these exceptions rarely, if at all.

We considered whether entities should be permitted to deny access to information based on a number of factors. For more specific discussion of access denials, please refer to earlier preamble text. For the purposes of the economic impacts, it is important to note that these denials are optional and, therefore, any costs associated with utilizing these denials are optional.

In § 164.514(c) and (d), we are proposing that covered plans and providers be required to have procedures that enable individuals to exercise their rights to inspect and obtain a copy of protected health information as explained above.

We considered whether this proposed rule should include detailed procedures governing a individual’s request for inspection and copying. Because this proposed rule would affect such a wide range of entities, we concluded that it should only provide general guidelines and that each entity should have the discretion to develop procedures consistent with its own size, systems, and operations.

In § 164.514(d)(2), we are proposing that the covered plans and providers would take action upon the request as soon as possible but not later than 30 days following receipt of the request. We considered the possibility of not including a time limitation but rather imposing a “reasonableness” requirement on the covered plans or providers. We concluded that the individual is entitled to know when to expect a response. This is particularly important in the context of health information, where an individual could need access to his or her information in order to make decisions about care. Therefore, in order to determine what would be “reasonable,” we examined the time limitations provided in the Privacy Act, the Freedom of Information Act (FOIA), and several State laws.

The Privacy Act requires that upon receipt of a request for amendment (not access), the agency would send an acknowledgment to the individual within 10 working days. (5 U.S.C. 552a (d)(2)). We considered several options that included such an acknowledgment requirement. An acknowledgment would be valuable because it would assure the individual that their request was received. Despite the potential value of requiring an acknowledgment, we concluded that it could impose a significant administrative burden on some of the covered plans and providers. This proposed rule would cover a wide range of entities with varying capacities and therefore, we are reluctant to create requirements that would overwhelm smaller entities or interfere too much with procedures already in place. We would encourage plans and providers to have an acknowledgment procedure in place, but would not require it at this point. We are soliciting comment on whether this proposed rule should require such an acknowledgment.

We also considered whether to include specific procedures governing “urgent” or “emergency” requests. Such procedures would require covered plans and providers to respond in a shorter time frame. We recognize that circumstances could arise where an individual would request inspection and copying on an expedited basis and we encourage covered plans or providers to have procedures in place for handling such requests. We are not proposing additional regulatory time limitations to govern in those circumstances. The 30-day time limitation is intended to be an outside deadline, rather than an expectation. Rather, we would expect a plan or provider to always be attentive to the circumstances surrounding each request and respond in an appropriate time frame, not to exceed 30 days.

Finally, we considered including a section governing when and how an entity could have an extension for responding to a request for inspection and copying. For example, the FOIA provides that an agency could request additional time to respond to a request if the agency needs to search for and collect the requested records from facilities that are separate from the office processing the request; to search for, collect, and appropriately examine a voluminous amount of separate and distinct records; and to consult with another entity or component having a substantial interest in the determination of the request. We determined that the criteria established in the FOIA are tailored to government information systems and therefore could not be appropriate for plans and providers covered by this proposed rule. Furthermore, we determined that the 30-day time period would be sufficient for responding to requests for inspection and copying and that extensions should not be necessary. We are soliciting comments on whether a structured extension procedure should be included in this proposed rule.

In § 164.514(d)(3), we are proposing that covered plans or providers be required to notify the individual of the decision to provide access and of any steps necessary to fulfill the request. In addition we propose that the entity provide the information requested in the form or format requested if it is readily producible in such form or format. Finally, if the covered plan or provider accepts an individual’s request, it would be required to facilitate the process of inspection and copying.

In proposed § 164.514(d)(3)(iv), we would permit a covered plan or provider to charge a reasonable, cost-based fee for copying health information provided pursuant to this section. We considered whether we should follow the practice in the FOIA and include a structured fee schedule. We concluded that the FOIA was developed to reflect the relatively uniform government costs and that this proposed rule would apply to a broader range of entities. Depending on the size of the entity, copying costs could vary significantly. Therefore, we propose that the entity simply charge a reasonable, cost-based fee.

In § 164.514(d)(4), we propose that a covered plan or provider that denies an individual’s request for inspection and copying in whole or in part be required to provide the individual with a written statement in plain language explaining the reason for the denial. The statement could include a direct reference to the section of the regulation relied upon for the denial, but the regulatory citation alone would not sufficiently explain the reason for the denial. The statement would need to include the name and number of the contact person or office within the entity who is responsible for receiving complaints. In addition, the statement would need to include information regarding the submission of a complaint with the Department pursuant to § 164.522(b).

We considered proposing that covered plans and providers provide a mechanism for appealing a denial of inspection and copying. We believe, however, that the requirement proposed in § 164.518(d) that covered plans and providers have complaint procedures to address patient and enrollee privacy issues generally would allow the individual to raise the issue of a denial with the covered plan or provider. We would expect the complaint procedures to be scalable; for example, a large plan might develop a standard complaint process in each location where it operates whereas, a small practice might simply refer the original request and denial to the clinician in charge for review. We would encourage covered plans and providers to institute a system of appeals, but would not require it by regulation. In addition, the individual would be permitted to file a complaint with the Department pursuant to § 164.522(b).