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privacy stuff. per wiki (I know, but linked source will be shown next) These rules apply to "covered entities" as defined by HIPAA and the HHS. Covered entities include health plans, health care clearinghouses, such as billing services and community health information systems, and health care providers that transmit health care data in a way that is regulated by HIPAA.<8><9> 8. http://frwebgate.access.gpo.gov/cgi-bin/get-cfr.cgi?TYPE=TEXT&YEAR=current&TITLE=45&PART=160&SECTION=1039. http://hipaa.ohio.gov/tools/CEDefinition.pdf (copy/pasted below, trying to figure it out if TSA is covered entity) I Definitions of a Covered Entity <45 C.F.R. 164.501> Covered Entities include: (1) Health plans (2) Health care clearinghouses (3) Health care providers who transmits any health information in electronic form in connection with a transaction covered by this subchapter. Covered Entity Definitions: Health care clearinghouse means a public or private entity that does either of the following (Entities, including but not limited to, billing services, repricing companies, community health management information systems or community health information systems, and “value-added” networks and switches are health care clearinghouses for purposes of this subchapter if they perform these functions.): (1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction. (2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity. Health care provider means a provider of services as defined in section 1861(u) of the Act, 42 U.S.C. 1395x(u), a provider of medical or other health services as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.
Health plan means an individual or group plan that provides, or pays the cost of, medical care (as
defined in section 2791(a)(2) of the PHS Act, 42 U.S.C. 300gg- 91(a)(2)).
(1) Health plan includes the following, singly or in combination:
II
(i) A group health plan, as defined in this section.
(ii) A health insurance issuer, as defined in this section.
(iii) An HMO, as defined in this section.
(iv) Part A or Part B of the Medicare program under title XVIII of the Act.
(v) The Medicaid program under title XIX of the Act, 42 U.S.C. 1396, et seq.
(vi) An issuer of a Medicare supplemental policy (as defined in section 1882(g)(1) of the Act, 42
U.S.C. 1395ss(g)(1)).
(vii) An issuer of a long-term care policy, excluding a nursing home fixed- indemnity policy.
(viii) 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.
(ix) The health care program for active military personnel under title 10 of the United States Code.
(x) The veterans health care program under 38 U.S.C. chapter 17.
(xi) The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)(as defined in
10 U.S.C. 1072(4)).
(xii) The Indian Health Service program under the Indian Health Care Improvement Act, 25 U.S.C.
1601, et seq.
(xiii) The Federal Employees Health Benefits Program under 5 U.S.C. 8902, et seq.
(xiv) An approved State child health plan under title XXI of the Act, providing benefits for child health
assistance that meet the requirements of section 2103 of the Act, 42 U.S.C. 1397, et seq.
(xv) The Medicare + Choice program under Part C of title XVIII of the Act, 42 U.S.C. 1395w-21
through 1395w-28.
(xvi) A high risk pool that is a mechanism established under State law to provide health insurance
coverage or comparable coverage to eligible individuals.
(xvii) Any other individual or group plan, or combination of individual or group plans, that provides or
pays for the cost of medical care (as defined in section 2791(a)(2) of the PHS Act, 42 U.S.C. 300ggIII
91(a)(2)).
(2) Health plan excludes:
(i) Any policy, plan, or program to the extent that it provides, or pays for the cost of, excepted benefits
that are listed in section 2791(c)(1) of the PHS Act, 42 U.S.C. 300gg-91(c)(1); and
(ii) A government-funded program (other than one listed in paragraph (1)(i)- (xvi)of this definition):
(A) Whose principal purpose is other than providing, or paying the cost of, health care; or
(B) Whose principal activity is:
(1) The direct provision of health care to persons; or
(2) The making of grants to fund the direct provision of health care to persons.
=====================================================================
42 U.S.C. 300gg-91(a)(2)
(2) Medical Care
The term “medical care” means amounts paid for -
(A) the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid
for the purpose of affecting any structure of function of the body,
(B) amounts paid for transportation primarily for and essential to medical care referred
to in subparagraph (A), and
(C) amounts paid for insurance covering medical care referred to in subparagraphs (A)
and (B).
IV
APPENDIX A
Code Provisions Referred to in Definition of Covered Provider
42 U.S.C. 1395x Subsection (u) and (s)
(u) Provider of services
The term ''provider of services'' means a hospital, critical access hospital,
skilled nursing facility, comprehensive outpatient rehabilitation facility, home
health agency, hospice program, or, for purposes of section 1395f(g) and
section 1395n(e) of this title, a fund.
--------------
(s) Medical and other health services
The term ''medical and other health services'' means any of the
following items or services:
(1) physicians' services;
(2)
(A) services and supplies (including drugs and
biologicals which cannot, as determined in accordance with
regulations, be self-administered) furnished as an incident to a
physician's professional service, of kinds which are commonly
furnished in physicians' offices and are commonly either rendered
without charge or included in the physicians' bills;
(B) hospital services (including drugs and biologicals which cannot, as
determined in accordance with regulations, be self-administered) incident to
physicians' services rendered to outpatients and partial hospitalization services
incident to such services;
(C) diagnostic services which are -
(i) furnished to an individual as an outpatient by a hospital or by others
under arrangements with them made by a hospital,
and
(ii) ordinarily furnished by such hospital (or by others under such
arrangements) to its outpatients for the purpose of diagnostic study;
(D) outpatient physical therapy services and outpatient occupational therapy
services;
(E) rural health clinic services and Federally qualified health center services;
(F) home dialysis supplies and equipment, self-care home dialysis support
services, and institutional dialysis services and supplies;
V
(G) antigens (subject to quantity limitations prescribed in regulations by the
Secretary) prepared by a physician, as defined in subsection (r)(1) of this
section, for a particular patient, including antigens so prepared which are
forwarded to another qualified person (including a rural health clinic) for
administration to such patient, from time to time, by or under the supervision of
another such physician;
(H) (i) services furnished pursuant to a contract under section 1395mm of
this title to a member of an eligible organization by a physician assistant
or by a nurse practitioner (as defined in subsection (aa)(5) of this
section) and such services and supplies furnished as an incident to his
service to such a member as would otherwise be covered under this part
if furnished by a physician or as an incident to a physician's service; and
(ii) services furnished pursuant to a risk-sharing contract under section
1395mm(g) of this title to a member of an eligible organization by a
clinical psychologist (as defined by the Secretary) or by a clinical social
worker (as defined in subsection (hh)(2) of this section), and such
services and supplies furnished as an incident to such clinical
psychologist's services or clinical social worker's services to such a
member as would otherwise be covered under this part if furnished by a
physician or as an incident to a physician's service;
(I) blood clotting factors, for hemophilia patients competent to use such
factors to control bleeding without medical or other supervision, and
items related to the administration of such factors, subject to utilization
controls deemed necessary by the Secretary for the efficient use of such
factors;
(J) prescription drugs used in immunosuppressive therapy furnished, to an
individual who receives an organ transplant for which payment is made
under this subchapter, but only in the case of drugs furnished -
(i) before 1995, within 12 months after the date of the transplant
procedure,
(ii) during 1995, within 18 months after the date of the transplant
procedure,
(iii) during 1996, within 24 months after the date of the transplant
procedure,
(iv) during 1997, within 30 months after the date of the transplant
procedure, and
(v) during any year after 1997, within 36 months after the date of
the transplant procedure;
(K) (i) services which would be physicians' services if furnished by a
physician (as defined in subsection (r)(1) of this section) and which are
performed by a physician assistant (as defined in subsection (aa)(5) of
VI
this section) under the supervision of a physician (as so defined) and
which the physician assistant is legally authorized to perform by the State
in which the services are performed, and such services and supplies
furnished as incident to such services as would be covered under
subparagraph (A) if furnished incident to a physician's professional
service; and <1> but only if no facility or other provider charges or is paid
any amounts with respect to the furnishing of such services, <2> (ii)
services which would be physicians' services if furnished by a physician
(as defined in subsection (r)(1) of this section) and which are performed
by a nurse practitioner or clinical nurse specialist (as defined in
subsection (aa)(5) of this section) working in collaboration (as defined in
subsection (aa)(6) of this section) with a physician (as defined in
subsection (r)(1) of this section) which the nurse practitioner or clinical
nurse specialist is legally authorized to perform by the State in which the
services are performed, and such services and supplies furnished as an
incident to such services as would be covered under subparagraph
(A) if furnished incident to a physician's professional service, but only if
no facility or other provider charges or is paid any amounts with respect
to the furnishing of such services;
(L) certified nurse-midwife services;
(M) qualified psychologist services;
(N) clinical social worker services (as defined in subsection (hh)(2) of this
section);
(O) erythropoietin for dialysis patients competent to use such drug without
medical or other supervision with respect to the administration of such
drug, subject to methods and standards established by the Secretary by
regulation for the safe and effective use of such drug, and items related
to the administration of such drug;
(P) prostate cancer screening tests (as defined in subsection (oo) of this
section);
(Q) an oral drug (which is approved by the Federal Food and Drug
Administration) prescribed for use as an anticancer chemotherapeutic
agent for a given indication, and containing an active ingredient (or
ingredients), which is the same indication and active ingredient (or
ingredients) as a drug which the carrier determines would be covered
pursuant to subparagraph (A) or (B) if the drug could not be
self-administered;
(R) colorectal cancer screening tests (as defined in subsection (pp) of this
section); and <1>
(S) diabetes outpatient self-management training services (as defined in
subsection (qq) of this section); and
VII
(T) an oral drug (which is approved by the Federal Food and Drug
Administration) prescribed for use as an acute anti-emetic used as part
of an anticancer chemotherapeutic regimen if the drug is administered by
a physician (or as prescribed by a physician) -
(i) for use immediately before, at, or within 48 hours after the time of the
administration of the anticancer chemotherapeutic agent; and
(ii) as a full replacement for the anti-emetic therapy which would
otherwise be administered intravenously. <3>
(3) diagnostic X-ray tests (including tests under the supervision of a physician, furnished
in a place of residence used as the patient's home, if the performance of such tests
meets such conditions relating to health and safety as the Secretary may find necessary
and including diagnostic mammography if conducted by a facility that has a certificate
(or provisional certificate) issued under section 354 of the Public Health Service Act
(42 U.S.C. 263b)), diagnostic laboratory tests, and other diagnostic tests;
(4) X-ray, radium, and radioactive isotope therapy, including materials and services of
technicians;
(5) surgical dressings, and splints, casts, and other devices used for reduction of
fractures and dislocations;
(6) durable medical equipment;
(7) ambulance service where the use of other methods of transportation is
contraindicated by the individual's condition, but only to the extent provided in
regulations;
(8) prosthetic devices (other than dental) which replace all or part of an internal body
organ (including colostomy bags and supplies directly related to colostomy care),
including replacement of such devices, and including one pair of conventional
eyeglasses or contact lenses furnished subsequent to each cataract surgery with
insertion of an intraocular lens;
(9) leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including
replacements if required because of a change in the patient's physical condition;
(10) (A) pneumococcal vaccine and its administration and, subject to section 4071(b)
of the Omnibus Budget Reconciliation Act of 1987, influenza vaccine and its
administration; and (B) hepatitis B vaccine and its administration, furnished to an
individual who is at high or intermediate risk of contracting hepatitis B (as
determined by the Secretary under regulations);
(11) services of a certified registered nurse anesthetist (as defined in subsection (bb) of
this section);
(12) subject to section 4072(e) of the Omnibus Budget Reconciliation Act of 1987,
extra-depth shoes with inserts or custom molded shoes with inserts for an individual
with diabetes, if -
(A) the physician who is managing the individual's diabetic condition (i)
documents that the individual has peripheral neuropathy with evidence of callus
VIII
formation, a history of pre-ulcerative calluses, a history of previous ulceration,
foot deformity, or previous amputation, or poor circulation, and
(ii) certifies that the individual needs such shoes under a comprehensive plan of
care related to the individual's diabetic condition;
(B) the particular type of shoes are prescribed by a podiatrist or other qualified
physician (as established by the Secretary); and
(C) the shoes are fitted and furnished by a podiatrist or other qualified individual
(such as a pedorthist or orthotist, as established by the Secretary) who is not
the physician described in subparagraph (A) (unless the Secretary finds that the
physician is the only such qualified individual in the area);
(13) screening mammography (as defined in subsection (jj) of this section);
(14) screening pap smear and screening pelvic exam; and
(15) bone mass measurement (as defined in subsection (rr) of this section). No
diagnostic tests performed in any laboratory, including a laboratory that is part of a rural
health clinic, or a hospital (which, for purposes of this sentence, means an institution
considered a hospital for purposes of section 1395f(d) of this title) shall be included
within paragraph (3) unless such laboratory -
(16) if situated in any State in which State or applicable local law provides for licensing
of establishments of this nature, (A) is licensed pursuant to such law, or (B) is
approved, by the agency of such State or locality responsible for licensing
establishments of this nature, as meeting the standards established for such licensing;
and
(17)(A) meets the certification requirements under section 353 of the Public Health
Service Act (42 U.S.C. 263a); and (B) meets such other conditions relating to the
health and safety of individuals with respect to whom such tests are performed as the
Secretary may find necessary. There shall be excluded from the diagnostic services
specified in paragraph (2)(C) any item or service (except services referred to in
paragraph (1)) which would not be included under subsection (b) of this section if it
were furnished to an inpatient of a hospital. None of the items and services referred to
in the preceding paragraphs (other than paragraphs (1) and (2)(A)) of this subsection
which are furnished to a patient of an institution which meets the definition of a hospital
for purposes of section 1395f(d) of this title shall be included unless such other
conditions are met as the Secretary may find necessary relating to health and safety of
individuals with respect to whom such items and services are furnished. |
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