Frequently Asked Questions
Who is required to comply with the HIPAA Administrative
Simplification regulations?
- Covered entities: Three categories
of "covered entities"1 are required to comply with all of the Administrative
Simplification regulations:
- Health plans
- Health care clearinghouses
- Health care providers that transmit health information
electronically in connection with a HIPAA transaction
- Health plans in local government:
Some cities and counties provide self-insured health,
dental and vision insurance to employees. These programs
may be affected by HIPAA because of their relationships
with "health plans." Workers' compensation
programs, however, are specifically excluded from
the definition of health plan.2
- Health care clearinghouses in local government:
A health care clearinghouse is generally defined as
an entity that converts information from one electronic
format into a HIPAA electronic format (and vice versa).
It is unlikely that a city or county owns or operates
a health care clearinghouse.
- Health care providers in local government:
Several different local government agencies may be
covered health care providers because they (1) meet
the HIPAA definition of "health care provider"
and (2) transmit health information electronically
in connection with a HIPAA transaction (such as filing
an insurance claim or verifying eligibility for insurance
coverage). The term "health care provider"
is defined very broadly to include any person or organization
that furnishes, bills or is paid for health care in
the normal course of business. For example, local
health departments, mental health area authorities,
departments of social services and emergency medical
services agencies may all be "health care providers"
that transmit HIPAA transactions electronically. Some
of these departments or agencies may serve multiple
counties. In some instances, counties contract with
private entities for the provision of some types of
health care (such as emergency medical services).
Back to Top
145 C.F.R. § 160.103
(definitions of "covered entity," "health
plan," "health care clearinghouse," and
"health care provider"); 45 C.F.R. Part 162
(definitions of HIPAA transactions, including claims,
eligibility verification, referral certification, enrollment
in a health plan, and payment).
245 C.F.R. § 160.103
(definition of "health plan" excludes programs
that provide for "excepted benefits" which
includes workers' compensation programs).
Back to FAQs |
