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HIPAA, Administrative Simplification, and ACA FAQs

A provider conducts no transactions electronically for which the Secretary of Health and Human Services has adopted a standard. Instead, the provider sends paper claims directly to a health plan, and the health plan transforms the paper claims into electronic formats in order to process and pay the claim. In this situation, is the provider a covered entity under HIPAA?


Q: A provider conducts no transactions electronically for which the Secretary of Health and Human Services has adopted a standard. Instead, the provider sends paper claims directly to a health plan, and the health plan transforms the paper claims into electronic formats in order to process and pay the claim. In this situation, is the provider a covered entity under HIPAA?

A: No. A health care provider becomes a covered health care provider if she/he transmits health information in an electronic format in order to conduct transactions that have been adopted by the HIPAA regulations as standard transactions. A health care provider who is not otherwise a covered health care provider does not become a covered entity if the health plan converts the paper claim into an electronic format for the health plan's own processing. Most, if not all, health plans transform the paper claims they receive into electronic formats for processing. The health plans do this for their own convenience, not on behalf of the providers submitting the paper claims. The provider described in the question would be a covered entity if its paper claims were submitted to a health care clearinghouse or a billing service, and, on behalf of the provider, that health care clearinghouse or the billing service transformed them into standard electronic transactions and transmitted them to a health plan.

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