Download PDF
Effective Date: April 10, 2017

HIPAA Policies for BU Health Plans: Policy 9, Definitions

Responsible Office Research Compliance

This Policy 9 is part of the HIPAA Policies for BU Health Plans Manual – Privacy and Security of Protected Health Information for BU Health Plans. Please refer to the Definitions section of the HIPAA Health Care Providers Policy 11: Definitions for general definitions. Additional definitions pertinent to the Health Plans follow.

Employee Services means the service center for the administration of BU benefit plans.

Group Health Plan means an employee welfare benefit plan (as defined in the Employee Retirement Income and Security Act of 1974), including insured and self-insured plans, to the extent that the plan provides medical care, including items and services paid for as medical care, to employees or their dependents directly or through insurance, reimbursement, or otherwise, that:

  • Has 50 or more Individuals, or
  • Is administered by an entity other than the employer that established and maintains the plan.

Health Insurance Issuer means an insurance company, insurance service, or insurance organization (including a Health Maintenance Organization) that is licensed to engage in the business of insurance in a state and is subject to state law that regulates insurance. Such term does not include a group health plan.

Health Plan means an individual plan or group health plan that provides, or pays the cost of medical care. A health plan includes the following, singly or in combination:

  • A Group Health Plan;
  • A Health Insurance Issuer;
  • A Health Maintenance Organization;
  • Part A or Part B of the Medicare program;
  • The Medicaid program;
  • 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 under the Indian Health Care Improvement Act;
  • The Federal Employees Health Benefits Program;
  • An approved State child Health Plan, providing benefits for child health assistance;
  • The Medicare + Choice program under Part C;
  • A high risk pool that is a mechanism established under State law to provide health insurance coverage or comparable coverage to eligible Individuals; or
  • Any other Individual or group plan, or combination of Individual or group plans, that provides or pays for the cost of medical care.

A Health Plan excludes:

  • Any policy, plan, or program to the extent that it provides, or pays for the cost of, excepted benefits.
  • A government-funded program (other than one listed in the above paragraph of this definition) whose principal purpose is other than providing, or paying the cost of, Health Care; or whose principal activity is:
    • The direct provision of Health Care to persons; or
    • The making of grants to fund the direct provision of Health Care to persons.

Payment means activities undertaken by a Health Plan (or by a Business Associate on behalf of a Health Plan) to determine its responsibilities for coverage under the Health Plan policy or contract including the actual Payment under the policy or contract, or by a Health Care Provider (or by a Business Associate on behalf of a provider) to obtain reimbursement for the provision of Health Care. Payment activities include, but are not limited to:

  • Determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), and adjudication or subrogation of health benefit claims;
  • Risk adjusting amounts due based on enrollee health status and demographic characteristics;
  • Billing, claims management, collection activities, obtaining Payment under a contract for reinsurance (including stop-loss insurance and excess of loss insurance), and related Health Care data processing;
  • Review of Health Care services with respect to medical necessity, coverage under a Health Plan, appropriateness of care, or justification of charges;
  • Utilization review activities, including precertification and preauthorization of services, concurrent and retrospective review of services; or
  • Disclosure to consumer reporting agencies of any of the following Protected Health Information relating to collection of premiums or reimbursement:
    • Name and address;
    • Date of birth;
    • Social security number;
    • Payment history;
    • Account number; and
    • Name and address of the Health Care Provider and/or Health Plan.

Plan Administration Functions means the administration functions performed by the Plan Sponsor of a Group Health Plan on behalf of the Group Health Plan and excludes functions performed by the plan sponsor in connection with any other benefit or benefit plan of the plan sponsor.

Summary Health Information means information that may be individually identifiable health information, and:

  • That summarizes the claims history, claims expenses, or type of claims experienced by Individuals for whom a plan sponsor has provided health benefits under a Group Health Plan; and
  • From which the information has been de-identified (see De-identification), except that the geographic information need only be aggregated to the level of a five-digit zip code.

Transaction means the transmission of information between two parties to carry out financial or administrative activities related to Health Care. A “Transaction” would mean any of the following:

  • Health claims or equivalent encounter information. This Transaction could be used to submit Health Care claim billing information, encounter information, or both, from Health Care Providers to payers, either directly or via intermediary billers and claims clearinghouses;
  • Health Care Payment and remittance advice. This Transaction could be used by a Health Plan to make a Payment to a financial institution for a Health Care Provider (sending Payment only), to send an explanation of benefits remittance advice directly to a Health Care Provider (sending data only), or to make Payment and send an explanation of benefits remittance advice to a health care provider via a financial institution (sending both Payment and data);
  • Coordination of benefits. This Transaction could be used to transmit Health Care claims and billing Payment information between payers with different Payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the furnishing, billing, and/or Payment of Health Care services within a specific Health Care/insurance industry segment;
  • Health claims status. This Transaction could be used by Health Care Providers and recipients of Health Care products or services (or their authorized agents) to request the status of a Health Care claim or encounter from a Health Plan;
  • Enrollment and disenrollment in a Health Plan. This Transaction could be used to establish communication between the sponsor of a health benefit and the payer. It provides enrollment data, such as subscriber and dependents, employer information, and primary care Health Care Provider information. A sponsor would be the backer of the coverage, benefit, or product. A sponsor could be an employer, union, government agency, association, or insurance company. The Health Plan would refer to an entity that pays claims, administers the insurance product or benefit, or both;
  • Eligibility for a Health Plan. This Transaction could be used to inquire about the eligibility, coverage, or benefits associated with a benefit plan, employer, plan sponsor, subscriber, or a dependent under the subscriber’s policy. It also could be used to communicate information about or changes to eligibility, coverage, or benefits from information sources (such as insurers, sponsors, and payers) to information receivers (such as physicians, hospitals, third party administrators, and government agencies);
  • Health Plan premium Payments. This Transaction could be used by, for example, employers, employees, unions, and associations to make and keep track of Payments of Health Plan premiums to their health insurers. This Transaction could also be used by a Health Care Provider, acting as liaison for the beneficiary, to make Payment to a health insurer for coinsurance, co-payments, and deductibles;
  • Referral certification and Authorization. This Transaction could be used to transmit Health Care service referral information between Health Care Providers, Health Care Providers furnishing services, and payers. It could also be used to obtain Authorization for certain Health Care services from a Health Plan;
  • First report of injury. This Transaction could be used to report information pertaining to an injury, illness, or incident to entities interested in the information for statistical, legal, claims, and risk management processing requirements;
  • Health claims attachments. This Transaction could be used to transmit Health Care service information, such as subscriber, patient, demographic, diagnosis, or Treatment data for the purpose of a request for review, certification, notification, or reporting the outcome of a Health Care services review; or
  • Other Transactions as the Secretary may prescribe by regulation. The Secretary may adopt Standards, and data elements for those Standards, for other financial and administrative Transactions deemed appropriate by the Secretary. These Transactions would be consistent with the goals of improving the operation of the Health Care system and reducing administrative costs.