If you are a “covered entity” then you or your organization needs to comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
This page provides initial guidance on how to determine whether you or your organization is a “covered entity”, under the Administrative Simplification provisions of HIPAA. Click here to get the full guide in PDF form from the website of the Centers for Medicare & Medicaid Services. Or, set a consultation with us to get a more thorough review of your status and your needs.
Are you (a person, business, or agency) a covered health care provider?
Do you, your business, or your agency furnish, bill, or receive payment for health care in the normal course of business? If the answer is NO (for example, if you provide coaching or seminars to other therapists), you can stop reading now. You are not a covered entity.
If you do provide health care services, including mental health care, then you will be considered a “covered entity” if you engage in “covered transactions”.
Bottom line: if you provide mental health care, you need to check if you are a covered entity. More on this in the following paragraphs.
What if I use a clearinghouse or other third party to process claims?
If you are a healthcare provider and you use a claims processing service (such as a clearinghouse) to conduct “covered transactions in electronic form,” then you meet the requirements and you will be considered a “covered entity”.
Bottom line: even if you use no computers in your practice, even if you have no electronic records or communications of any kind with your clients, if you use a clearinghouse or third-party service for your back office finance – you are considered to be conducting the transaction in electronic form.
What the heck is a “covered transaction” for HIPAA?
For your convenience, we have distilled the specifications for what defines covered transaction in the following points. (If you really want to know more, see below for the the standards defined in 45 C.F.R. Part 162.)
Bottom line: If you use only paper, fax or telephone in your office – you may be okay. But, if not, a covered transaction includes any of the following:
- A request for payment.
- Transmission of encounter information (such as, Provider A met Client B).
- A request for information to a health plan (such as, is Client C eligible for benefits).
- A request for the review of health care.
- A request for information about the status of a health care claim.
- Transmission from a health plan to you or your bank about payment or payment processing.
- Transmission from a health plan with explanation of benefits or remittance.
So, you are a covered entity. What does this mean for online sessions?
If you are not a covered entity, you are free to provide online sessions using Skype or whatever tools that you prefer. If, however, you are a covered entity – you need to get a solution for online therapy sessions that conforms to HIPAA requirements.
Click here to find out how you can get HIPAA compliant email through G Suite, including a Business Associate Agreement with Google.
If you really want to know – the gist of 45 C.F.R. Part 162
If you really want to plunge in, here are some of the nitty gritty of the HIPAA definitions.
45 C.F.R.162.1101: Health care claims or equivalent encounter information transaction is either of the following:
(a) A request to obtain payment, and necessary accompanying information, from a health care provider to a health plan, for health care.
(b) If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.
45 C.F.R.162.1201: The eligibility for a health plan transaction is the transmission of either of the following:
(a) An inquiry from a health care provider to a health plan or from one health plan to another health plan, to obtain any of the following information about a benefit plan for an enrollee:
(1) Eligibility to receive health care under the health plan.
(2) Coverage of health care under the health plan.
(3) Benefits associated with the benefit plan.
(b) A response from a health plan to a health care provider’s (or another health plan’s) inquiry described in paragraph (a) of this section.
45 C.F.R.162.1301: The referral certification and authorization transaction is any of the following transmissions:
(a) A request for the review of health care to obtain an authorization for the health care.
(b) A request to obtain authorization for referring an individual to another health care provider.
(c) A response to a request described in paragraph (a) or paragraph (b) of this section.
45 C.F.R.162.1401: A health care claim status transaction is the transmission of either of the following:
(a) An inquiry to determine the status of a health care claim.
(b) A response about the status of a health care claim.
45 C.F.R.162.1501: The enrollment and disenrollment in a health plan transaction is the transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage.
45 C.F.R.162.1601: The health care payment and remittance advice transaction is the transmission of either of the following for health care:
(a) The transmission of any of the following from a health plan to a health care provider’s financial institution:
(2) Information about the transfer of funds.
(3) Payment processing information.
(b) The transmission of either of the following from a health plan to a health care provider: (1) Explanation of benefits. (2) Remittance advice.
45 C.F.R.162.1701: The health plan premium payment transaction is the transmission of any of the following from the entity that is arranging for the provision of health care or is providing health care coverage payments for an individual to a health plan:
(b) Information about the transfer of funds.
(c) Detailed remittance information about individuals for whom premiums are being paid.
(d) Payment processing information to transmit health care premium payments including any of the following:
(1) Payroll deductions.
(2) Other group premium payments.
(3) Associated group premium payment information.
45 C.F.R.162.1801: The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of the health plan, of either of the following for health care:
(b) Payment informationPlease share this post!