Tuesday, December 8, 2009

Can a billing service be a business associate of a covered entity and not be a health care clearinghouse?

Question: Can a billing service be a business associate of a covered entity and not be a health care clearinghouse?

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Answer : Yes; a billing service may be a business associate of a covered entity and not be considered a health care clearinghouse. Example: Billing Service 3 is a Business Associate but is NOT a Health Care Clearinghouse. A health care provider has a contractual arrangement with Billing Service 3 whereby Billing Service 3 conducts various claims preparation services and then transmits non-standard claims to Health Care Clearinghouse B for conversion into standard format and transmission to the health plan. The health care provider has a contractual arrangement with Health Care Clearinghouse B whereby Health Care Clearinghouse B receives the non-standard claims from Billing Service 3, converts the data to standard, and transmits the standard claim to a health plan. The health care provider is a covered entity because it is, through Health Care Clearinghouse B, transmitting a standard claim transaction to a health plan. Because Billing Service 3 is performing claims preparation services on behalf of a covered entity, Billing Service 3 is a business associate. Billing Service 3 is not a health care clearinghouse because it neither converts non-standard (paper or electronic) data into the standard claim transaction, nor does it out-source this function.

What are Companion Guides? Where do I get them?

Question: What are Companion Guides? Where do I get them?

Answer : Companion Guides are health plan-specific versions of the HIPAA-adopted standard Implementation Guides that define the health plans’ requirements for situational data elements, and provide special instructions and further guidance on how the health plan is interpreting the HIPAA Implementation Guides. While HIPAA adopted specific Implementation Guides, Companion Guides have been independently created by some health plans to supplement the HIPAA Implementation Guides and are tailored to meet individual health plans’ particular needs. Companion Guides are not required by HIPAA, and all health plans are not publishing Companion Guides. These guides cannot:
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1-Change the definition, data condition, or use of a data element or segment in a standard.
2-Add any data elements or segments to the maximum defined data set.
3-Use any code or data elements that are either marked “not used” in the standard’s implementation specification or are not in the standard’s implementation specification(s).
4-Change the meaning or intent of the standard’s implementation specification(s).

Companion Guides may be requested from specific health plans that have published them.

How does the Small Business Administration definition change affect the HIPAA definition?

Question: How does the Small Business Administration definition change affect the HIPAA definition?

Answer : The Small Business Administration has changed its definition of a “small business concern” from an entity that receives less than $5 million in receipts annually to an entity that receives less than $6 million.
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This change does not affect the HIPAA definition. While HHS relied on advice from the Small Business Administration in developing its definition of a small health plan, it did not formally adopt the Small Business Administration definition as the definition for HIPAA purposes. For HIPAA purposes, a small health plan remains an entity that has receipts of $5 million or less per year.

'small health plan'

Question: How should a health plan determine what receipts to use to decide whether it qualifies as a 'small health plan'?

Answer
A small health plan is defined at 45 C.F.R.§ 160.103 as “a health plan with annual receipts of $5 million or less.” Health plans that report receipts to the IRS on identified tax forms. Health plans that file certain federal tax returns and report receipts on those returns should use the following guidance provided by the Small Business Administration at 13 C.F.R. § 121.104 to calculate annual receipts: Receipts means 'total income' (or in the case of a sole proprietorship, 'gross income') plus 'cost of goods sold' as these terms are defined or reported on Internal Revenue Service (IRS) Federal tax return forms; Form 1120 for corporations; Form 1120S for Subchapter S corporations; Form 1065 for partnerships; and Form 1040, Schedule F for farm or Schedule C for sole proprietorships).
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However, the term “receipts” excludes net capital gains or losses, taxes collected for and remitted to a taxing authority if included in gross or total income, proceeds from the transactions between a concern and its domestic or foreign affiliates (if also excluded from gross or total income on a consolidated return filed with the IRS), and amounts collected for another by a travel agent, real estate agent, advertising agent, conference management service provider, freight forwarder or customs broker.In calculating receipts under this guidance, health plans should use the definitions and process described at 13 C.F.R. § 121.104(a)(2) - (3) and § 121.104(b).•Health plans that do not report receipts to the IRS on identified tax forms.
•Health plans that do not report receipts to the IRS – for example, ERISA group health plans that are exempt from filing income tax returns – should use proxy measures to determine their annual receipts. Fully insured health plans should use the amount of total premiums which they paid for health insurance benefits during the plan’s last full fiscal year. Self-insured plans, both funded and unfunded, should use the total amount paid for health care claims by the employer, plan sponsor or benefit fund, as applicable to their circumstances, on behalf of the plan during the plan’s last full fiscal year. Those plans that provide health benefits through a mix of purchased insurance and self-insurance should combine the proxy measures to determine their total annual receipts.

Are credit card transactions covered under HIPAA?

Question: Are credit card transactions covered under HIPAA? If an individual (i.e., a subscriber or a patient) uses his or her credit or debit card to pay for premiums, deductibles and/or co-payments, is that “transaction” considered a HIPAA standard, and must it be in a HIPAA compliant format with HIPAA compliant content?


Answer: The HIPAA standards must be used by “covered entities,” which are health plans, health care clearinghouses and health care providers who conduct any of the standard transactions electronically. The HIPAA standards do not apply to individuals, unless they are acting in some capacity on behalf of a covered entity, and not on behalf of themselves as, for example, subscribers or patients.
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An individual, acting on behalf of himself or herself, is not a covered entity, and is therefore not subject to the HIPAA standards. Transactions conducted between subscribers or patients and health plans or health care providers are not transactions for which the Secretary of Health and Human Services has adopted standards. Therefore, if an individual uses a personal credit card or debit card to pay either a premium, co-payment and/or deductible to a health plan or a health care provider, the individuals are not covered entities, they are not conducting covered transactions, and the transactions being conducted need not be in the standard format.