De-Identification of PHI

Op10.03-4 De-Identification of PHI

Applies to the Administrative Requirements of the Health Insurance Portability and Accountability Act of 1996. 45 CFR Section 164.514(a)-(c)

Policy

The Employee Benefit Plan may use de-identified health information when individually identifiable health information is not necessary or is not permitted under the Privacy Rules.

Procedure

The Employee Benefit Plan may use de-identified health information provided the identifiers of the participant or dependents are removed and there is no reasonable basis to believe that the remaining information used alone or in combination with other information would identify the individual that is the subject of the information.

The following identifiers must be removed to de-identify data set: 

  • Names 
  • All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Census: 
    • The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and 
    • The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000. 
  • All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; 
  • Telephone numbers; 
  • Fax numbers; 
  • Social security numbers; 
  • Electronic mail addresses;
  • Medical record numbers; 
  • Employee Benefit plan beneficiary numbers; 
  • Account numbers; 
  • Certificate/license numbers;
  • Vehicle identifiers and serial numbers, including license plate numbers; 
  • Device identifiers and serial numbers;
  • Web Universal Resource Locators (URLs); 
  • Internet Protocol (IP) address numbers;
  • Biometric identifiers, including finger and voice prints; 
  • Full Face photographic images and any comparable images; and 
  • Any other unique identifying number, characteristic, or code except as permitted in c above.

The Employee Benefit Plan may assign a code or other means of record identification to allow information that has been de-identified to be re-identified, provided that:

  • The code or other means of record identification is not derived from or related to information about the individual and is not otherwise capable of being translated so as to identify the individual by any reasonably anticipated recipient of the de-identified data; and
  • The Employee Benefit Plan does not use or disclose the code or other means of record identification for any other purpose, and does not disclose the mechanism for re-identification.

Effective Date: April 14, 2003