Compliance, fraud prevention, and privacy programs

Compliance program and code of conduct

Blue Shield of California Promise Health Plan commits to following all guidelines of the Department of Health Care Services (DHCS), Department of Managed Care (DMHC), and other related bodies. We always strive to act with integrity and honesty. We also comply with the law, our policies, and the Blue Shield Corporate Compliance and Ethics Program. We hold ourselves – and our partners and providers – to these standards.

• Compliance program (PDF, 250 KB)
• Code of conduct (PDF, 2 MB)

Our standards include identifying and working quickly to fix non-compliance. When we do identify non-compliance, we act.

Corrective actions

• DHCS Medical Audit CAP (PDF, 152 KB)

Healthcare fraud, waste, and abuse

We want you to understand what healthcare fraud is. Healthcare fraud costs the United States about $60 billion annually. That’s why we want you to know what fraud and abuse is. It’s also important for you to know how to report fraud. When you see something suspicious, report it.

What is fraud?
Fraud occurs when someone tries to get something of value by purposely lying, forging, or concealing. There are many types of fraud, and people commit fraud for various reasons. Fraud in the healthcare system is no exception.

Healthcare fraud may be an organized effort by a provider, member, or anyone else to cheat the system. It may also be the action of a lone provider who bends the rules to serve the perceived needs of a patient. These are two of many examples. Healthcare fraud is a serious and growing problem. It exploits patients and robs them of care critical to their well-being.

Examples of common types of healthcare fraud include:

• Provider fraud
• Billing for services not provided or “free services”
• Unbundling or up-coding (incorrect reporting to maximize payments)
• Waiving deductibles and/or copayments
• Falsifying dates or descriptions of services
• Billing non-covered services as covered items
• Subscriber/member fraud
• Loaning an ID card to someone else
• Changing amounts charged on claim forms or prescription receipts
• Filing false claims
• Non-subscriber or non-member fraud
• Using a stolen ID card to receive medical services

Privacy

Our privacy commitment

At Blue Shield Promise, we understand the importance of keeping your personal information private. We take our obligation to do so very seriously.

In the normal course of doing business, we create records about you, your medical treatment, and the services we provide. Those records are protected health information (PHI). PHI usually includes your name, address, phone number, Social Security number, and health information. This may include healthcare diagnoses or claim information.

Federal and state law requires us to give you this notice of our legal duties and privacy practices about your PHI. We will maintain the privacy of your PHI and let you know if your PHI is breached.

Los Angeles
English: Notice of privacy practices (PDF, 879 KB)
Arabic: Notice of privacy practices (PDF, 1 MB)
Armenian: Notice of privacy practices (PDF, 1 MB)
Chinese (Traditional): Notice of privacy practices (PDF, 1.3 MB)
Cambodian (Khmer): Notice of privacy practices (PDF, 1 MB)
Farsi (Persian): Notice of privacy practices (PDF, 1 MB)
Korean: Notice of privacy practices (PDF, 982 KB)
Russian: Notice of privacy practices (PDF, 938 KB)
Spanish: Notice of privacy practices (PDF, 884 KB)
Tagalog: Notice of privacy practices (PDF, 884 KB)
Vietnamese: Notice of privacy practices (PDF, 946 KB)

San Diego
English: Notice of privacy practices (PDF, 436 KB)
Arabic: Notice of privacy practices (PDF, 676 KB) 
Chinese (Traditional): Notice of privacy practices (PDF, 927 KB) 
Farsi (Persian): Notice of privacy practices (PDF, 678 KB) 
Spanish: Notice of privacy practices (PDF, 515 KB)
Tagalog: Notice of privacy practices (PDF, 516 KB) 
Vietnamese: Notice of privacy practices (PDF, 578 KB)
 

Privacy forms
Use this form to allow Blue Shield Promise to disclose your PHI:  

Authorization for the Use or Disclosure of Health Information, English (PDF, 296 KB)
Authorization for the Use or Disclosure of Health Information, Chinese (PDF, 403 KB)
Authorization for the Use or Disclosure of Health Information, Hindi (PDF, 450 KB)
Authorization for the Use or Disclosure of Health Information, Korean (PDF, 546 KB)
Authorization for the Use or Disclosure of Health Information, Spanish (PDF, 298 KB)
Authorization for the Use or Disclosure of Health Information, Vietnamese (PDF, 498 KB)

Guarding your privacy

Find fraud prevention resources that teach you how to spot fraud, protect yourself, and take action. Learn more about medical identity theft:

 Medical identity theft information (PDF, 744 KB)
 List of resources (PDF, 34 KB)

Delegation oversight 

Blue Shield Promise is committed to doing the right thing for our members. Our Delegation model (PDF, 133 KB) helps ensure the proper performance of our delegates. Data on our delegates can be found in our Delegation Reporting and Compliance Plan (PDF, 1.5 MB).

Reporting violations

You can report compliance and privacy concerns in various ways. And you may do so anonymously. To submit a report:

Compliance and/or fraud

• Report online at Blueshieldcaexternal.ethicspoint.com
• Call (855) 296-9083, toll-free in the U.S. and Canada
• Email Promisestopfraud@blueshieldca.com

Privacy

• Report online at bsc.i-sight.com/portal/reportonline.
• Call (855) 296-9086
• Email privacy@blueshieldca.com