The definition of business associates includes an entity performing functions such as claims processing or administration. (160.103) The general requirements for covered entities pertaining to transactions, allows use of a business associate to conduct a transaction for the entity, but the entity must require the business associate to conduct the transaction in compliance with the rule. 162.923(c).
A clearinghouse is described as an entity that processes of facilitates processing of data from another entity (here the definition seems to fit the scenario) in a nonstandard format/content to a standard (or vice versa) - and here the scenario doesn't seem to fit. Thus, as Rachel points out, it appears that the entity is acting more like a "plain" business associate, than a clearinghouse business associate. This scenario is complicated by the fact that providers are sending paper. Therefore, HIPAA TCS really isn't applicable to the situation because paper processes aren't regulated. The health plan still has to offer an EDI compliant method to receive claims and other transactions and may elect to use the same entity that processes paper. In this case, the claims processor would need to accept compliant EDI from the providers or accept non-compliant and translate to compliant transactions. In the latter case, they would appear to be a clearinghouse, whereas in the former, it appears they are still just acting as a business associate. Regards, Leah Hole-Curry FOX Systems, Inc. 602.708.1045 Information transmitted is confidential and may be proprietary to FOX Systems, Inc. It is intended only for the person or entity to which it is addressed. Anyone else is prohibited from disclosing, copying, or disseminating the contents or attachments. If you receive this in error, please notify sender immediately, or us at www.foxsys.com and delete from your system. >>> [EMAIL PROTECTED] 06/24/02 11:47 AM >>> I think that there is still fuzziness in the legal definitions of a clearinghouse and when an entity is not a clearinghouse. I don't believe that how this company in question reports its business activities that its performing on behalf of the health plan nor how the health plan pays it for these business services is pertinent to determining its role of either solely a business associate or both a business associate and a clearinghouse. Since the provider is not aware of this company's existence, it operates on the assumption that it is dealing directly with the health plan/payer. Thus, the provider is not choosing to use a clearinghouse. As far as it's concerned, it is sending its paper claims to the payer for adjudication and payment. Further, this company is not reformatting the non-standard data/format into the standard and then sending it on to the health plan/payer. It is actually entering the claim data into an adjudication system, which then determines what if any, payment shall be made. The company then makes the payment, all on behalf of the health plan/payer using the payer's logo, identity, etc. Thus, in my opinion, it is not acting in the role of a clearinghouse, but rather acting in the role of the payer.\ But, again, the final decision on this issue won't be decided here on this listserv; rather, both the payer and its business associate and their respective legal counsel must evaluate the law and regs and reach a determination. Rachel -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Monday, June 24, 2002 1:07 PM To: [EMAIL PROTECTED]|; [EMAIL PROTECTED] Subject: Re: A Clearinghouse By Any Other Name ... The original scenario does not indiciate how this business activity is reported to the health plan, or how the entity gets paid for the payments it makes to the providers. Does it make a difference if the business associate/(clearinghouse?) reformats the data to feed directly into the healthplan's claim file? How is this different from a clearinghouse that is used by both the provider and the health plan? Susan Miller [EMAIL PROTECTED] ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ====================================================== The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. 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