Certain information must be obtained prior to releasing or discussing any information regarding a specific Medicare beneficiary file via telephone or written contact. Protecting the privacy of your Medicare records is mandated by the Federal Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Note: If only general Medicare information is requested, privacy requirements are not applied.

Please note that privacy guidelines to appeal a claim determination differ from the guidelines for general questions answered by the Customer Service area.

1.  Customer ServcePrivacy Requirements:

Beneficiary Calling:

• Your full name
• Your date of birth
• Your Medicare number as shown on your Medicare card
• Another piece of information such as your address

Other Inquirers Calling on Behalf of the Beneficiary:

• If a family member or friend calls our office about information on a Medicare file, we will need to obtain verbal permission directly from the beneficiary; (Exception: If the caller has a Medicare Summary Notice (MSN) and meets the privacy requirements listed above for the beneficiary, the customer service representative can discuss the services listed on the specific MSN) ;or
• Our office has a written consent form (Medicare Information Release Form – MIRF) that can be completed which allows our customer service representatives to release information on the beneficiary’s Medicare file to a designated individual.

Medicare Information Release Form (MIRF)

Medicare beneficiaries should complete this form to designate a party to act on his/her behalf when calling Highmark Medicare Servicesregarding his/her Medicare file. Send the completed form to:

Highmark Medicare Services
Attn: Privacy-Customer Service
P.O. Box 890125
Camp Hill, PA 17089-0125

 Download MIRF Form In PDF Format

 Download MIRF Form In Microsoft Word Format

2. Telephone Appeals (1-866-488-0551) Privacy Requirements

Beneficiary Calling:

• Your full name
• Your date of birth
• Your Medicare number as shown on your Medicare card

Review Requests on Behalf of the Beneficiary:

• If a family member or friend calls our office to request a review for you, we will need a completed Appointed Representative form or a copy of a Power of Attorney document. An Appointed Representative form is valid for one year from the date that you sign it.
• A copy of the form is needed each time an appeal is requested.
• For a deceased beneficiary, a legal representative of the estate can initiate appeals. A copy of the will, short certificate or probate court document must be provided.

Appointed Representative Form

Medicare beneficiaries should complete this form to designate a party to request a review on his/her behalf. Send the completed form to:

Highmark Medicare Services
Attn: Privacy - Appeals Dept
P.O. Box 890413
Camp Hill, PA 17089-0413

OR

Fax 717-730-1588

Click Here To Download Appointed Representative Form In PDF Format

3.   Written Privacy Requirements

General Information

Certain information must be included when writing to our office regarding a Medicare file.   Individuals other than the beneficiary, regardless of relationship, may not receive information about an individual without the beneficiary’s written consent.

The following individuals can receive information if the criteria are met in each category:

• Beneficiary/Representative Payee:  All information may be released.  Please include the beneficiary's full name and complete Medicare number on all written requests sent to our office.
• Power-of-Attorney (POA):  A POA representing a beneficiary must include a copy of the POA.  This document must include a raised seal or a copy of the raised seal and define or limit what powers the person can exercise.  The Medicare number and the beneficiary’s complete name must be included in the request.  All original documents will be returned to the inquirer.
• Executor/Executrix:  A deceased beneficiary's estate may need to contact our office regarding the Medicare files.  A copy of the Short Certificate with a raised seal is needed to change or request information.  All original documents will be returned to the inquirer.
• Other Inquirers:  A written, signed, and dated authorization from the beneficiary must accompany the request.  Specific information that can be released should be included on the statement.  Each time an inquiry is received, all the above data must be included for our office to reply with the requested information.

Note:   When requesting an address change, we require the beneficiary's complete name, complete Medicare number, date of birth, and signature.   A phone number can also be included in order for our office to respond by telephone.

Direct Written Inquiries to:
Highmark Medicare Services
General Information
P.O. Box 890413
Camp Hill, PA 07089-0413

Written Appeal Requests

All of the information under General Information applies to Written Appeal Requests plus the appointed representative information listed below.

Appointed Representative appeal request: The original appointment must accompany the first appeal request. A copy of the appointment must accompany each review request thereafter in which a beneficiary opts to use an appointed representative.

Click Here To Download Appointed Representative Form In PDF Format