Glossary

A contractor hired under this SOW.

A coordinating body within HHS that has high-level responsibility for overseeing the implementation of the A/S provisions of HIPAA.

A covered entity may use or disclose PHI only:

• With the consent of the individual for treatment, payment, or health care operations;
• With the authorization of the individual for all other uses or disclosures;
• As permitted under this rule for certain public policy purposes.

A covered entity whose covered functions are not its primary functions.

A data dictionary that defines and cross-references the contents of all X12 transactions included in the HIPAA mandate. It is maintained by X12N/TG3.

A decision made to either pay in full, pay in part, or deny a claim. (See also Initial Claim Determination.)

A decision that an incorrect amount of money has been paid for Medicare services and a determination of what that amount is.

A decision that your Private Fee-for-Service Plan makes on whether or not it will pay for a certain service.

A description of the circumstances in which certain data is required.

A determination as defined in 42 CFR §405.1801 under the definition for Intermediary Determination.