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 they transmit 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 their 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.