HIPAA, Administrative Simplification, and ACA FAQs

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. The provider 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.