HIPAA DECISION TREE

HIPAA defines a health care provider as a provider of medical or health services and any other person or organization that furnishes, bills or is paid for "health care" in the normal course of business. For ease of determining whether an ISPA member is a covered health care provider, follow the HIPAA Decision Tree below:

1. If you/your company does not furnish, bill or receive payment for health care in the normal course of business, then STOP: you/your company is not a covered health care provider.
2. If you or your company does furnish, bill or receives payment for health care in the normal course of business, then the next question you must ask is: do you or your company conduct "covered transactions"?
3. If not, then STOP: you/your company is not a covered health care provider.
4. If you/your company does conduct covered transactions, then the next question you must ask is: are any of the covered transactions transmitted in "electronic form"?
5. If not, then STOP: you/your company is not a covered health care provider.
6. If the covered transactions are transmitted in electronic form, then you/your company is a covered health care provider and is required to comply with HIPAA.

"Health care" means: care, services or supplies related to the health of an individual, including but not limited to: preventive, diagnostic, rehabilitative, maintenance or palliative care and counseling, service, assessment or procedure with respect to the physical or mental condition or functional status of an individual or that affects the structure or function of the body, and sale or dispensing of a drug, device, equipment or other item in accordance with a prescription.

"Covered transactions" include the following: transmitting health care claims to request and obtain payment; transmitting encounter information for the purpose of recording health care; referral certification and authorization for health care; transmitting a health care claim status inquiry or response.

"Electronic form" means: using electronic media, electronic storage media (hard drives, magnetic tape, disks, memory cards) or transmission media used to exchange information already in electronic storage media (internet, extranet. Certain transactions, including of paper, via facsimile, and of voice via telephone, are NOT considered to be transmissions via electronic media.