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Covered Entity Decision Tools
Background
The Administrative Simplification 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 (called here a "covered health
care provider")
- a health care clearinghouse
- a health plan
- An entity that is one or more of these
types of entities is referred to as a "covered entity" in the
Administrative Simplification regulations.
Decision Tools
Is a Person, Business, or Agency a Covered
Health Care Provider?
- Does the person, business, or agency
furnish, bill or receive payment for health care in the normal course of
business?
- Does the person, business, or agency
conduct covered transactions?
- Are any of the covered transactions
transmitted in electronic form?
Is a Business or Agency a Health Care
Clearinghouse?
- 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?
- Does the business or agency perform this
function for another legal entity?
Is a Private Benefit Plan a Health Plan?
- Is the plan an individual or group plan,
or combination thereof, that provides, or pays for the cost of, medical
care?
- Is the plan a group health plan?
- Does the plan have both of the following
characteristics: (a) it has fewer than 50 participants, and (b) it is
self-administered?
Is a Government-Funded Program a Health
Plan?
- Is the program one of the listed
government health plans?
Covered Entity Charts
This guidance on how to determine whether an
entity is a covered entity under the Administrative Simplification
provisions of HIPAA is also available in a Covered
Entity Flowchart (PDF, 61.4KB).
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