This Covered Entity Decision Questionnaire is Free and does not require an Email to use. You can use it as often as you like.
The questionnaire will help you determine whether an organization or individual is a covered entity under the Health Insurance Portability and Accountability Act (HIPAA).
The Centers for Medicare & Medicaid Services (CMS) developed a Covered Entity Decision Tool as an interactive PDF document. This questionnaire follows the documented process flow but is more user-friendly.
What is a Covered Entity?
Individuals and organizations that must comply with HIPAA are called Covered Entities, which include Health Plans, Clearinghouses, and certain Healthcare Providers.
Health Plans
For HIPAA purposes, health plans include:
- Health insurance companies
- HMOs, or health maintenance organizations
- Employer-sponsored health plans
- Government programs that pay for health care, like Medicare, Medicaid, and military and veterans’ health programs
Clearinghouses
Clearinghouses include organizations that process nonstandard health information to conform to data content or format standards, or vice versa, on behalf of other organizations.
Providers
Providers who electronically submit HIPAA transactions, like claims, are covered. These providers include, but are not limited to:
- Doctors
- Clinics
- Psychologists
- Dentists
- Chiropractors
- Nursing homes
- Pharmacies
About Business Associates
Suppose a covered entity engages a business associate to help carry out its healthcare activities and functions. In that case, the covered entity must have a written business associate contract or other arrangement with the business associate that:
- Establishes specifically what the business associate has been engaged to do
- Requires the business associate to comply with HIPAA
Examples of business associates include:
- Third-party administrator that assists a health plan with claims processing
- A consultant who performs utilization reviews for a hospital
- Healthcare clearinghouse that translates a claim from a nonstandard format into a standard transaction on behalf of a healthcare provider and forwards the processed transaction to a payer
- Independent medical transcriptionist that provides transcription services to a physician
Also, a covered healthcare provider, health plan, or healthcare clearinghouse can be a business associate of another covered entity.
Exceptions
An organization may request an exception from using a standard transaction from the Secretary to test a proposed modification to that standard. Learn more about the exception process and the principles for requesting an exception (PDF).