How to determine whether you are an entity is covered under the Administrative Simplification provisions of HIPAA. The standards adopted by HIPAA applies to any entity that is:

1. A health care provider that conducts certain transactions in electronic form, which is called a "covered health care provider."
1. Business associates
2. Other doctors in your office
3. Contract workers
4. Independent contractors
2. Any health care clearinghouses
3. Any health plan
4. Billing services
5. Insurance payments

An entity that is one or more of these types of entities is referred to as a "covered entity."

Is a person, business, or agency a covered health care provider? Most private physicians and physician groups fall into this category.

1. Does the person, business, or agency furnish, bill, or receive payments for health care in the normal course of business? If you answered yes, then does the person, business, or agency conduct covered transactions? If you answered yes, then are the covered transactions transmitted in electronic form? If you answered yes, then the person, business, or agency is a covered health care provider.
2. Does the person, business or agency furnish, bill, or receive payment for health care in the normal course of business? Does the person, business, or agency conduct covered transactions? Are any of the transactions transmitted in electronic form? If you answered no to these questions, then the person, business, or agency is not a covered health care provider.

Health care means care, services, or supplies related to the health of an individual, which includes preventive, diagnosis, rehabilitative, maintenance, or palliative care, and counseling, services, assessment, or procedures to the physical, mental, or functional status of an individual or that affects the structure or function of the body.

Covered transactions: Electronic billing will eventually replace all paper billing with insurance companies. If the health care provider uses another entity (third-party payor) to conduct covered transactions in electronic form on its behalf, the health care provider is considered to be conducting the transaction in electronic form; the health care provider is a covered entity conducting covered transactions.

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Transaction Standards

Transaction standards (effective in 2002): This deals with the method of electronic transmission of health care information through the use of specific management and HIPAA-compliant software. Electronic form means: Using electronic media, and electronic storage media, including memory devices in computers (hard drives) and any removable, transportable digital memory medium used to exchange information in any electronic form. Transmission includes the Internet, recorded or written in any form created or received by the health care provider, and relates to past, present, or future physical condition of the individual. Also included are leased and dial-up lines, and private networks. Paper transactions, facsimiles, and voice via the telephone are not considered to be transmissions via electronic media, because the information being exchanged did not exist in electronic form before the transmission.

Medical care means amounts paid for the following: diagnosis, cure, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body.

Kenneth Ross, DC, JD, is a retired criminal law enforcement officer and graduate of law school in 2000. He practices in Orlando, Fla, and lectures nationally in areas of medical fraud, claims review, risk management, medical records, and medical documentation. He can be reached at (866) 225-5055 or at .