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§ 142.103 Definitions.For purposes of this part, the following definitions apply:
Code set means any set of codes used for
encoding data elements, such as tables of terms, medical concepts, medical
diagnostic codes, or medical procedure codes.
Health care clearinghouse
means a public or
private entity that processes or facilitates the processing of nonstandard data
elements of health information into standard data elements. The entity receives
health care transactions from health care providers or other entities,
translates the data from a given format into one acceptable to the intended
payer or payers, and forwards the processed transaction to appropriate payers
and clearinghouses. Billing services, repricing companies, community health
management information systems, community health information systems, and
“value-added” networks and switches are considered to be health care
clearinghouses for purposes of this part.
Health care provider means a provider of
services as defined in section 1861(u) of the Social Security Act, 42 U.S.C.
1395x, a provider of medical or other health services as defined in section
1861(s) of the Social Security Act, and any other person who furnishes or bills
and is paid for health care services or supplies in the normal course of
business.
Health information means any information,
whether oral or recorded in any form or medium, that--
(1) Is created or received by a
health care provider, health
plan, public health authority, employer, life insurer, school or university,
or health care clearinghouse; and(2) Relates to the past, present, or future physical or
mental health or condition of an individual, the provision of health care to
an individual, or the past, present, or future payment for the provision of
health care to an individual.
Health plan means an individual or group plan
that provides, or pays the cost of, medical care. Health plan includes the
following, singly or in combination:
(1) Group health plan. A group health plan is an employee
welfare benefit plan (as currently defined in section 3(1) of the Employee
Retirement Income and Security Act of 1974, 29 U.S.C. 1002(1)), including
insured and self- insured plans, to the extent that the plan provides medical
care, including items and services paid for as medical
care, to employees or
their dependents directly or through insurance, or otherwise, and--
(i) Has 50 or more
participants; or
(ii) Is administered by an entity other than the employer
that established and maintains the plan.
(2) Health insurance issuer. A health insurance issuer is an
insurance company, insurance service, or insurance organization that is
licensed to engage in the business of insurance in a State and is subject to
State law that regulates insurance.
(3) Health maintenance organization. A health maintenance
organization is a Federally qualified health maintenance organization, an
organization recognized as a health maintenance organization under State law,
or a similar organization regulated for solvency under State law in the same
manner and to the same extent as such a health maintenance organization.
(4) Part A or Part B of the Medicare program under title
XVIII of the Social Security Act.
(5) The Medicaid program under title XIX of the Social
Security Act.
(6) A Medicare supplemental policy (as defined in section
1882(g)(1) of the Social Security Act, 42 U.S.C. 1395ss).
(7) A long-term care policy, including a nursing home
fixed-indemnity policy.
(8) 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.
(9) The health care program for active military personnel
under title 10 of the United States Code.
(10) The veterans health care program under 38 U.S.C.
chapter 17.
(11) The Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS), as defined in 10 U.S.C. 1072(4).
(12) The Indian Health Service program under the Indian
Health Care Improvement Act (25 U.S.C. 1601 et seq.).
(13) The Federal Employees Health Benefits Program under 5
U.S.C. chapter 89.
(14) Any other individual or group health plan, or
combination thereof, that provides or pays for the cost of medical
care.
Medical care means the diagnosis, cure,
mitigation, treatment, or prevention of disease, or amounts paid for the purpose
of affecting any body structure or function of the body; amounts paid for
transportation primarily for and essential to these items; and amounts paid for
insurance covering the items and the transportation specified in this
definition.
Participant means any employee or former
employee of an employer, or any member or former member of an employee
organization, who is or may become eligible to receive a benefit of any type
from an employee benefit plan that covers employees of that employer or members
of such an organization, or whose beneficiaries may be eligible to receive any
of these benefits. "Employee" includes an individual who is treated as
an employee under section 401(c)(1) of the Internal Revenue Code of 1986 (26
U.S.C. 401(c)(1)).
Small health plan means a group health plan or
individual health plan with fewer than 50 participants.
Standard means a set of rules for a set of
codes, data elements, transactions, or identifiers promulgated either by an
organization accredited by the American National Standards Institute or HHS for
the electronic transmission of health information.
Transaction means the exchange of information
between two parties to carry out financial and administrative activities related
to health care. It includes the following:
(1) Health claims or equivalent encounter information.
(2) Health care payment and remittance advice.
(3) Coordination of benefits.
(4) Health claims status.
(5) Enrollment and disenrollment in a
health plan.
(6) Eligibility for a
health plan.
(7)
Health plan premium payments.
(8) Referral certification and authorization.
(9) First report of injury.
(10) Health claims attachments.
(11) Other transactions as the Secretary may prescribe by
regulation.
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