Covered Entities
Administrative Simplification defines a covered entity as one of the following:
- a health plan,
- a health care clearinghouse, or
- a health care provider
who transmits any health information in electronic form in connection with a covered transaction.
Health Plans - means an individual or group plan that provides, or pays the cost of medical care, including, when applied to government funded programs, the components of the government agency administering the program. A health plan includes the following, singly or in combination:
- A group health plan.
- A health insurance issuer.
- An HMO.
- Part A or Part B of the Medicare program under title XVIII of the Act.
- The Medicaid program under title XIX.
- An issuer of a Medicare supplemental policy.
- An issuer of a long-term care policy, excluding a nursing home fixed-indemnity policy.
- An employee welfare benefit plan or any other arrangement that is established or maintained for the purpose of offering or providing health benefits to the employees of two or more employers.
- The health care program for active military personnel.
- The veterans health care program.
- The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
- The Indian Health Service program.
- The Federal Employees Health Benefit Program.
- An approved State child health plan under title XXI.
- The Medicare + Choice program under part C of title XVIII.
- Any other individual or group plan, or combination of individual or group plans, that provides or pays for
the cost of medical care.
Health Care Clearinghouses - a public or private entity that does either of the following:
- Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction.
- Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity.
Health Care Providers - means a provider of services and any other person or organization that furnishes, bills, or is paid for health care in the normal course of business.
Office of Civil Rights - More information can be found at the Office of Civil Rights' Medical Privacy page including a "Covered Entity Decision Tools" easy-to-use question and answer decision tool.
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