2. Question 2: Do you conduct
covered transactions, as that is defined below? If you do not conduct
any of the following transaction, HIPAA does not apply to you. A covered
transaction is any one of the following and if you conduct any covered
transaction, you must answer Question Number 3, below:
a. Submission of a request to
obtain payment, along with necessary accompanying information, from
a health care provider to a health plan, for health care; or, if there
is no direct payment claim, because the reimbursement contract is based
on a mechanism other than charges or reimbursement rates for specific
services, the transaction is the transmission of encounter information
for the purpose of reporting the provision of health care services.
b. Determination of eligibility
for a health plan transaction through transmission of:
(i) an inquiry from a health care provider to a health
plan, or from one health plan to another health plan, to obtain any
of the following information about a benefit plan for an enrollee:
(a) Eligibility to receive health
care under the health plan.
(b) Coverage of health care under
the health plan.
(c) Benefits associated with
the benefit plan.
(ii) a response from a health plan to a health care provider's (or another health plan's) inquiry described above in paragraph (i) of this section.
c. A referral certification and
authorization transaction is any of the following transmissions:
(i) A request for the review
of health care to obtain an authorization for the provision of health
care.
(ii) A request to obtain authorization
for referring an individual to another health care provider.
(iii) A response to a request
described in paragraph (i) or paragraph (ii) of this section.
d. A health care claim status
transaction is the transmission of either of the following:
(i) An inquiry to determine the
status of a health care claim.
(ii) A response about the status
of a health care claim.
e. The enrollment and disenrollment
in a health plan transaction is the transmission of subscriber enrollment
information to a health plan to establish or terminate insurance coverage.
f. The health care payment and
remittance advice transaction is the transmission of either of the following
for health care:
(i) The transmission of any
of the following from a health plan to a health care provider's financial
institution:
(a) Payment.
(b) Information about the transfer
of funds.
(c) Payment processing information.
(ii) The transmission of either
of the following from a health plan to a health care provider:
(a) Explanation of benefits.
(b) Remittance advice.
g. The health plan premium payment
transaction is the transmission of any of the following from the entity
that is arranging for the provision of health care or is providing health
care coverage payments for an individual to a health plan:
(i) Payment.
(ii) Information about the transfer
of funds.
(iii) Detailed remittance information
about individuals for whom premiums are being paid.
(iv) Payment processing information
to transmit health care premium payments including any of the following:
(a) Payroll deductions.
(b) Other group premium payments.
(c) Associated group premium
payment information.
h. The coordination of benefits
transaction is the transmission from any entity to a health plan for
the purpose of determining the relative payment responsibilities of
the health plan, of either of the following for health care:
(i) Claims.
(ii) Payment information.
3. Question 3: Are any of the
foregoing covered transactions transmitted in electronic form? If not,
HIPAA does not apply to you. Is yes, then you must comply with the HIPAA
Privacy Rule.
Note: If you do not currently
submit any claims to any payor, including Medicare, or engage in any
covered transaction, as that is defined above, you do not have to comply
with the HIPAA Privacy Rule. However, if you currently submit paper
claims to Medicare and you have more than 10 employees, including administrative
and office personnel, you will have to convert to electronic claims
submission by October, 2003 and comply with HIPAA by April, 2003. If
you have fewer than 10 employees, you are not required to convert to
electronic claims submission and you do not have to comply with HIPAA.
