Covered Entity Guidance - PDF document

1  Covered Entity Guidance Find out w
 Covered Entity Guidance Find out whether an organization or individual is a covered entity under the Administrative Simpli�cation provisions of HIPAA \r\f\n\t\b&

2 #15;  The Administrative Simpli
#15;  The Administrative Simpli�cation standards adopted by HHS under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) apply to any entity that is: • A health care provider that conducts certain transactions in electronic form ( • A health care clearinghouse, or • A health plans of entities is referred to as a “covered entity” in the Administra

3 tive Simpli�cation regulation
tive Simpli�cation regulations, and must comply with the How to Use This ToolTo determine if a person, business, or government agency is a covered entity, go to to the person, business, or agency, and answer the questions.or special meanings are set out in the endnotes. The number for the appropriate  Is a person, business, or agency a covered Is a business or agency a health care

4 plan a health plan? Is a government- fun
plan a health plan? Is a government- funded program a  Covered Entity Guidance: Q: Does the person, business, or agency furnish, , health care in the normal course of business? 1 Yes No  Q: Does the person, business, or agency transmit (send) any covered transactions electronically? Q: Does the person, business, or agency furnish, bill, or receive payment for health

5 A: Yes Yes No Covered Entity Guidance:
A: Yes Yes No Covered Entity Guidance:  The person, business, or agency is NOT a covered health care provider and therefore not a covered entity.Q: Does the person, business, or agency furnish, bill, or receive payment for health Return to Start Covered Entity Guidance:
The person, business, or agency is a covered health care provider and therefore a covered entity. ered transactions A: Yes

6 Return to Start Covered Entity Guidance
Return to Start Covered Entity Guidance: The person, business, or agency is NOT a covered health care provider and therefore not a covered entity.ered transactions Covered Entity Guidance:  \r\f\n&#

7 20;\t\b &#
20;\t\b  Covered Entity Guidance: Clearinghouses Q: Does the business or agency process, or facilitate the processing of, health information from nonstandard format or content into standard format or content or from standard format or content into nonstandard format or content? 3 Yes No  Q: Does the business or agency perform

8 this function for another legal enti
this function for another legal entity? ssing of, health rmat or content or A: Yes Yes No Covered Entity Guidance:  clearinghouse and therefore not a covered entity.ssing of, health rmat or content or Covered Entity Guidance:  The business or agency is a health care clearinghouse and therefore a covered entity.A: Yes Return to Start Covered Entity Guidance:  The business

9 or agency is NOT a health care clearing
or agency is NOT a health care clearinghouse and therefore not a covered entity. Covered Entity Guidance:  Covered Entity Guidance: Q: Is the plan an individual or group plan, or combination thereof, that provides, or pays for the cost of, medical care? 4 Yes No  a covered entity.eof, that provides, or Covered Entity Guidance:  Q: Is the plan a group health

10 plan? eof, that provides, or A: Yes Yes
plan? eof, that provides, or A: Yes Yes No Covered Entity Guidance: 
Q: Does the plan have both of the following characteristics: (a) it has fewer than 50 participants and (b) it is self-administered? A: Yes Yes No Covered Entity Guidance:  Q: Is the plan a health insurance issuer? 7 Yes No Covered Entity Guidance:  a covered entity.) it has fewer than 50 A: Y

11 esCovered Entity Guidance: Return to St
esCovered Entity Guidance: Return to Start  The plan is a health plan and therefore a covered entity.) it has fewer than 50 Return to Start Covered Entity Guidance:  The plan is a health plan and therefore a covered entity.A: Yes Return to Start Covered Entity Guidance:  Q: Is the plan an issuer of a Medicare supplemental policy? 8 Yes No Covered Entity Guidance:

12  The plan is a health plan and
 The plan is a health plan and therefore a covered entity.A: Yes Return to Start Covered Entity Guidance:  Q: Is the plan a health maintenance organization (HMO)? 9 Yes No Covered Entity Guidance:  The plan is a health plan and therefore a covered entity.A: Yes Return to Start Covered Entity Guidance:  Is the plan a multi-employer welfare bene�t

13 Yes No Covered Entity Guidance: &#
Yes No Covered Entity Guidance: 
The plan is a health plan and therefore a covered entity.A: Yes Return to Start Covered Entity Guidance:  Q: Is the plan an issuer of long-term care policies? Yes No Covered Entity Guidance:  Q: Does the plan provide only nursing home A: Yes Yes No Covered Entity Guidance:  11 Yes No Covered Entity Guidance: 

14 The plan is NOT a health plan and theref
The plan is NOT a health plan and therefore not a covered entity.A: Yes Return to Start Covered Entity Guidance:  The plan is a health plan and therefore a covered entity. Return to Start Covered Entity Guidance:  The plan is NOT a health plan and therefore not a covered entity.A: Yes Return to Start Covered Entity Guidance:  The plan is a health plan and therefore a covered

15 entity. Return to Start Covered Entity G
entity. Return to Start Covered Entity Guidance:  Covered Entity Guidance: Q: Is the program one of the listed government health plans? 12 Yes No  The plan is a health plan and therefore a covered entity.A: Yes Return to Start Covered Entity Guidance: 
Q: Is the program an individual or group plan that provides, or pays the cost of, medical care? 4 Yes

16 No Covered Entity Guidance:  Q:
No Covered Entity Guidance:  Q: Is the program a high risk pool? pays the cost of, A: Yes Yes No Covered Entity Guidance:  The plan is NOT a health plan and therefore not a covered entity. pays the cost of, Return to Start Covered Entity Guidance:  The plan is a health plan and therefore a covered entity.A: Yes Return to Start Covered Entity Guidance:  Q: Is

17 the plan a health maintenance organizat
the plan a health maintenance organization (HMO)? 9 Yes No Covered Entity Guidance:  The plan is a health plan and therefore a covered entity.A: Yes Return to Start Covered Entity Guidance:  Q: Is the principal activity of the program providing health care directly? Yes No Covered Entity Guidance:  The plan is NOT a health plan and therefore not a covered entit

18 y.A: Yes Return to Start Covered Entity
y.A: Yes Return to Start Covered Entity Guidance:  Q: Is the principal activity of the program the making of grants to fund the direct provision of health care (e.g., through funding a health clinic)? Yes No Covered Entity Guidance:  The plan is NOT a health plan and therefore not a covered entity.s to fund the direct A: Yes Return to Start Covered Entity Guidance:

19 
Q: Is the principal purpose

Q: Is the principal purpose of the program other than providing or paying the cost of health care (e.g., operating a prison system, running a scholarship or fellowship program)? s to fund the direct Yes No Covered Entity Guidance:  The plan is NOT a health plan and therefore not a covered entity. or paying the cost larship or fellowship A: Yes Return to Start Covered Ent

20 ity Guidance:  or paying t
ity Guidance:  or paying the cost larship or fellowship Yes No Covered Entity Guidance:  The plan is NOT a health plan and therefore not a covered entity.A: Yes Return to Start Covered Entity Guidance:  The plan is a health plan and therefore a covered entity. Return to Start Covered Entity Guidance:  1. Health care means: dual. It includes, but ehabilitative

21 , maintenance, or palliative care, to t
, maintenance, or palliative care, to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and (2) Sale or dance with a prescription. See 45 C.F.R.160.103 2. Covered transactions the standards are at 45 C.F.R. Part 162 A transaction is a covered transaction if it meets the regulatory de�nition for the type

22 of transaction. 45 C.F.R.162.1101 (a)
of transaction. 45 C.F.R.162.1101 (a) A request to obtain payment, and necessary accompanying information, from a  45 C.F.R.162.1201(a) An inquiry from a health care provider to a health plan or from one health plan to another health (b) A response from a health plan to a health care provider’s (or another health plan’s) 45 C.F.R.162.1301: The referral certi�cation and a

23 uthorization transaction is any of (a) A
uthorization transaction is any of (a) A request for the review of health care to obtain an authorization for the health care.(b) A request to obtain authorization for referring an individual to another health care provider.(c) A response to a request described in paragraph (a) or paragraph (b) of this section. 45 C.F.R.162.1401: A health care claim status transaction is the transmission of either Covere

24 d Entity Guidance:  (a) An inqu
d Entity Guidance:  (a) An inquiry to determine the status of a health care claim.(b) A response about the status of a health care claim.45 C.F.R.162.1501: The enrollment and disenrollment in a health plan transaction is the transmission of 45 C.F.R.162.1601: The health care payment and remittance advice transaction is the transmission (a) The transmission of any of the following from a health pl

25 an to a health care provider’s (b) The
an to a health care provider’s (b) The transmission of either of the following from a health plan to a health care provider:45 C.F.R.162.1701: The health plan premium payment transaction is the transmission of Covered Entity Guidance:  (3) Associated group premium payment information.45 C.F.R.162.1801: The coordination of bene�ts transaction is the transmission from any As pertinen

26 t here, a is a “public or private ent
t here, a is a “public or private entity... Covered Entity Guidance:  for the receiving entity.” See 45 C.F.R. 160.103A “standard transaction,” for the purpose of this de�nition, is a transaction that complies 45 C.F.R. 162.103prevention of disease, or amounts paid for the purpose of affecting any structure or function 5. A group health plan is: an employee welfare bene

27 60069;t plan (as de�ned in se
60069;t plan (as de�ned in section 3(1) of the Employee Retirement Income and Security Act of 1974 (ERISA), 29 U.S.C. nt that the plan provides care, to employees or or otherwise, that: (1) tered by an entity other 45 C.F.R. 160.1036. A participant means: any employee or former employee of an employer, or any member or former le to receive a bene�t of any type from Covered Entity Gu

28 idance: 
or member of such org
idance: 
or member of such organization, or 7. A health insurance insurer is: an insurance company, insurance service or insurance organization f insurance in a state and is subject to a group health plan). 45 C.F.R. 160.1038. An issuer of a Medicare supplemental policy is: a private entity that offers a health o are entitled to have payments made red for services and items reimbursable by rea

29 son her limitations imposed pursuant to
son her limitations imposed pursuant to or other limitations imposed by Medicare. A Medicare supplemental policy does not include policies ty Act. See 9. A health maintenance organization is:state law, or a similar organization regulated for solvency under state law in the same manner 45 C.F.R. 160.10310. A multi-employer welfare program is:45 C.F.R.160.103 Covered Entity Guidance:  11.Excepted bene

30 �ts are: 12.Government-funde
�ts are: 12.Government-funded health plans are: the Medicare program under Title XVIII of the Social Security Act (Parts A, B and C) ( under Title XIX of the Social Security Act (45 CFR Parts and approved state child health programs under Title XXI of the Social Security Act 13.A high risk pool is Covered Entity Guidance: 

31 
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32 \b The bus
\b The business or agency is NOT a health care clearinghouse and therefore not a covered entity.ssing of, health rmat or content or Return to Start Covered Entity Guidance:  a covered entity.) it has fewer than 50 A: YesCovered Entity Guidance: Return to Start  a covered entity.eof, that provides, or Covered Entity Guidance:  The business o

33 r agency is NOT a health care clearingho
r agency is NOT a health care clearinghouse and therefore not a covered entity. Re overed Entity Guidance:  \r\f\n\t\b  The business or agency is NOT a

34 health care clearinghouse and therefore
health care clearinghouse and therefore not a covered entity. Re overed Entity Guidance: \r\f\n\t\b  The business or agency is NOT a health care clearinghou

35 se and therefore not a covered entity.
se and therefore not a covered entity. Re overed Entity Guidance:  \r\f\n\t\b &

36 #29;&
#29;\r\f\n\t\b \r\f\n\t\b

37 5;  The plan is a health
5;  The plan is a health plan and therefore a ) it has fewer than 50 Return to Start Covered Entity Guidance:  a covered entity.) it has fewer than 50 A: Yes Covered Entity Guidance: Return to Start  Q: Is the plan a health insurance issuer? 7 Yes No Covered Entity Guidance: 
Q: Does the plan have both of the following characteristics: (a) it has fewer t

38 han 50 participants and (b) it is sel
han 50 participants and (b) it is self-administered? A: Yes Yes No Covered Entity Guidance:  Q: Is the plan a group health plan? eof, that provides, or A: Yes Yes No Covered Entity Guidance:  Q: Does the business or agency perform this function for another legal entity? ssing of, health rmat or content or A: Yes Yes No Covered Entity Guidance: Clearinghouses  Covere

39 d Entity Guidance: Clearinghouses Q:
d Entity Guidance: Clearinghouses Q: Does the business or agency process, or facilitate the processing of, health information from nonstandard format or content into standard format or content or from standard format or content into nonstandard format or content? 3 Yes No The person, business, or agency is NOT a covered health care provider and therefore not a covered entity.ered transac

40 tions Covered Entity Guidance:
Th
tions Covered Entity Guidance:
The person, business, or agency is a covered health care provider and therefore a covered entity. ered transactions A: Yes Return to Start Covered Entity Guidance:  The person, business, or agency is NOT a covered health care provider and therefore not a covered entity.Q: Does the person, business, or agency furnish, bill, or receive payment for health Return

41 to Start Covered Entity Guidance: 
to Start Covered Entity Guidance:  Q: Does the person, business, or agency transmit (send) any covered transactions electronically? Q: Does the person, business, or agency furnish, bill, or receive payment for health A: Yes Yes No Covered Entity Guidance:  Covered Entity Guidance: Q: Does the person, business, or agency furnish, bill, or receive payment for, health care in the norma

42 l course of business? 1 Yes No 
l course of business? 1 Yes No  a covered entity.eof, that provides, or Return to Start Covered Entity Guidance:  Covered Entity Guidance: Q: Is the plan an individual or group plan, or combination thereof, that provides, or pays for the cost of, medical care? 4 Yes No  The business or agency is a health care clearinghouse and therefore a covered entity.A: Yes Return to S

43 tart Covered Entity Guidance: Clearingh
tart Covered Entity Guidance: Clearinghouses The business or agency is NOT a health care clearinghouse and therefore not a covered entity.ssing of, health rmat or content or Covered Entity Guidance:  The plan is a health plan and therefore a A: Yes Return to Start Covered Entity Guidance:  Q: Is the plan a health maintenance organization (HMO)? 9 Yes No Covered Entity Guid

44 ance:  The plan is a health pla
ance:  The plan is a health plan and therefore a A: Yes Return to Start Covered Entity Guidance:  Q: Is the plan an issuer of a Medicare supplemental policy? 8 Yes No Covered Entity Guidance:  The plan is a health plan and therefore a A: Yes Return to Start Covered Entity Guidance: The business or agency is NOT a health care clearinghouse and therefore not a cove

45 red entity.ssing of, health rmat or cont
red entity.ssing of, health rmat or content or Covered Entity Guidance:   The plan is a health plan and therefore a covered entity. Return to Start Covered Entity Guidance:  Does the program provide only excepted or paying the cost larship or fellowship Yes No Covered Entity Guidance:  Q: Is the principal activity of the program the making of grants to fund t

46 he direct provision of health care (e.g
he direct provision of health care (e.g., through funding a health clinic)? Yes No Covered Entity Guidance:  Q: Is the principal activity of the program providing health care directly? Yes No Covered Entity Guidance:  Q: Is the plan a health maintenance organization (HMO)? 9 Yes No Covered Entity Guidance:  The plan is a health plan and therefore a A: Yes

47 Return to Start Covered Entity Guidance
Return to Start Covered Entity Guidance: 
Q: Is the program an individual or group plan that provides, or pays the cost of, medical care? 4 Yes No Covered Entity Guidance:  The plan is a health plan and therefore a A: Yes Return to Start Covered Entity Guidance:  The plan is a health plan and therefore a covered entity. Return to Start Covered Entity Guidance: &

48 #6; The plan is a health plan and theref
#6; The plan is a health plan and therefore a covered entity. Return to Start Covered Entity Guidance:  Does the plan provide only excepted 11 Yes No Covered Entity Guidance:  Q: Does the plan provide only nursing home A: Yes Yes No Covered Entity Guidance:  Q: Is the plan an issuer of long-term care policies? Yes No Covered Entity Guidance: 
The plan is a

49 health plan and therefore a A: Yes Ret
health plan and therefore a A: Yes Return to Start Covered Entity Guidance:  Is the plan a multi-employer welfare bene�t plan? 10 Yes No Covered Entity Guidance: 
or member of such organization, or 7.A health insurance insurer is: an insurance company, insurance service or insurance organizationf insurance in a state and is subject to a group health plan). 45 C.F.R. 160.

50 1038.An issuer of a Medicare supplementa
1038.An issuer of a Medicare supplemental policy is: a private entity that offers a health o are entitled to have payments made red for services and items reimbursable by reason her limitations imposed pursuant to or other limitations imposed by Medicare. A Medicare supplemental policy does not include policies ty Act. See 9.A health maintenance organization is: 45 C.F.R. 160.10310.A multi-employer wel

51 fare program is: Covered Entity Guidance
fare program is: Covered Entity Guidance:  45 C.F.R. 160.103A “standard transaction,” for the purpose of this de�nition, is a transaction that complies 45 C.F.R. 162.1034.Medical care means: 5.A group health plan is: Act of 1974 (ERISA), 29 U.S.C. nt that the plan provides care, to employees or or otherwise, that: (1) tered by an entity other 6.A participant means: any employe

52 e or former employee of an employer, or
e or former employee of an employer, or any member or formerle to receive a bene�t of any type from Covered Entity Guidance:  (3) Associated group premium payment information.45 C.F.R.162.1801: The coordination of bene�ts transaction is the transmission from any is a “public or private entity... Covered Entity Guidance:  (a) An inquiry to determine the status

53 of a health care claim.(b) A response a
of a health care claim.(b) A response about the status of a health care claim.45 C.F.R.162.1501: The enrollment and disenrollment in a health plan transaction is the transmission of 45 C.F.R.162.1601: The health care payment and remittance advice transaction is the transmission (a) The transmission of any of the following from a health plan to a health care provider’s (b) The transmission of either of

54 the following from a health plan to a he
the following from a health plan to a health care provider:45 C.F.R.162.1701: The health plan premium payment transaction is the transmission of Covered Entity Guidance:  45 C.F.R.162.1201(a) An inquiry from a health care provider to a health plan or from one health plan to another health (b) A response from a health plan to a health care provider’s (or another health plan’s) 45 C.F.R.162.13

55 01: The referral certi�cation
01: The referral certi�cation and authorization transaction is any of (a) A request for the review of health care to obtain an authorization for the health care.(b) A request to obtain authorization for referring an individual to another health care provider.(c) A response to a request described in paragraph (a) or paragraph (b) of this section. 45 C.F.R.162.1401: A health care claim status tra

56 nsaction is the transmission of either
nsaction is the transmission of either Covered Entity Guidance:  1.Health care means:ehabilitative, maintenance, or palliative care, to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and (2) Sale or dance with a prescription. 45 C.F.R.160.1032.Covered transactions 45 C.F.R. Part 162 A transaction is a covered transa

57 ction if it meets the regulatory de�
ction if it meets the regulatory de�nition for the type of transaction. 45 C.F.R.162.1101 (a) A request to obtain payment, and necessary accompanying information, from a  The business or agency is NOT a health care clearinghouse and therefore not a covered entity. Re overed Entity Guidance:  a covered entity.) it has fewer than 50 A: Yes Covered Entity Guidance: Return

58 to Start  a covered entity.eof,
to Start  a covered entity.eof, that provides, or Return to Start Covered Entity Guidance: The business or agency is NOT a health care clearinghouse and therefore not a covered entity.ssing of, health rmat or content or Covered Entity Guidance:   a covered entity.eof, that provides, or Return to Start Covered Entity Guidance:  a covered entity.) it has fewer th