The Definition of Payment

This posting is one of several that outline the HITECH privacy provisions of the American Recovery and Reinvestment Act that President Obama signed into law on Tuesday, February 17, 2009, in Denver, CO. Here, we reproduce the definitions that appear in Subtitle D—Privacy, Section 13400. Definitions, that appear in the Conference Report on page H1345 of Congressional Record—House, February 12, 2009. These definitions are critical in understanding the content of the new HITECH privacy provisions and how they relate to existing HIPAA Administrative Simplification Privacy Rule standards.

HIPAA Privacy Definitions:

Breach Business Associate Covered Entity Disclosure Electronic Health Record Health Care Operations

Health Care Provider Health Plan National Coordinator Payment Personal Health Record Protected Health Information

Secretary Security State Treatment Use Vendor Of Personal Health Records

PAYMENT

The term ‘payment’ has the meaning given such term in section 164.501 of title 45, Code of Federal Regulations.

Section 164.501—

Payment means:

(1) The activities undertaken by:

(i) A health plan to obtain premiums or to determine or fulfill its responsibility for coverage and provision of benefits under the health plan; or

(ii) A covered health care provider or health plan to obtain or provide reimbursement for the provision of health care; and

(2) The activities in paragraph (1) of this definition related to the individual to whom health care is provided and include, but are not limited to:

(i) Determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), and adjudication or subrogation of health benefit claims;

(ii) Risk adjusting amounts due based on enrollee health status and demographic characteristics;

(iii) Billing, claims management, collection activities, obtaining payment under a contract for reinsurance (including stop-loss insurance and excess of loss insurance), and related health care data processing;

(iv) Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges;

(v) Utilization review activities, including precertification and preauthorization of services, concurrent and retrospective review of services; and

(vi) Disclosure to consumer reporting agencies of any of the following protected health information relating to collection of premiums or reimbursement:

(A) Name and address;

(B) Date of birth;

(C) Social Security number;

(D) Payment history;

(E) Account number; and

(F) Name and address of the health care provider and/or health plan.