The standards in this proposed regulation would apply to all health plans, all health care clearinghouses, and all health care providers that transmit health information in an electronic form in connection with a standard transaction. In this proposed rule, these entities are referred to as “covered entities.” See definition at proposed § 160.103.
A health plan is defined by section 1171 to be an individual or group plan that provides for, or pays the cost of, medical care. The statute expressly includes a significant group of employee welfare benefit plans, state-regulated insurance plans, managed care plans, and essentially all government health plans, including Medicare, Medicaid, the veterans health care program, and plans participating in the Federal Employees Health Benefits Program. See discussion of the definition in section II.B.
A health care provider would be a provider of services as defined in section 1861(u) of the Act, 42 U.S.C. 1395x, a provider of medical or other health services as defined in section 1861(s) of the Act, and any other person who furnishes, bills or is paid for health care services or supplies in the normal course of business. See discussion of the definition in section II.B. Health care providers would be subject to the provisions of the rule if they transmit health information in electronic form in connection with a standard transaction. Standard transactions include claims and equivalent encounter information, eligibility and enrollment transactions, premium payments, claims attachments, and others. See proposed § 160.103. Health care providers who themselves do not directly conduct electronic transactions would become subject to the provisions of the proposed rule if another entity, such as a billing agent or hospital, transmits health information in electronic form in connection with a standard transaction on their behalf.
A health care clearinghouse would be a public or private entity that processes or facilitates the processing of nonstandard data elements of health information into standard data elements. See section 1171(2) of the Act. For purposes of this rule, we would consider billing services, repricing companies, community health management information systems or community health information systems, "value-added" networks, switches and similar organizations to be health care clearinghouses for purposes of this part only if they actually perform the same functions as a health care clearinghouse. See discussion of the definition in section II.B.