Like health
care operations, payment receives a very expansive definition
under HIPAA. The term principally
includes activities undertaken by:
health plans,
to obtain premiums from covered individuals or to provide
reimbursement to providers of health care services; and
health care
providers, to obtain reimbursement for such services.
Such activities
include, but are not limited to:
determinations
of eligibility or coverage (including coordination of benefits
or the determination of cost sharing amounts);
adjudication
or subrogation of health benefit claims;
risk adjustment
activities based on enrollee health status and demographic
characteristics;
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;
review of health
care services with respect to medical necessity, coverage
under a health plan, appropriateness of care, or justification
of charges;
utilization
review activities, including precertification and preauthorization
of services, concurrent and retrospective review of services;
and
disclosure to
consumer reporting agencies of any of the following protected
health information relating to collection of premiums
or reimbursement: name and address, date of birth, social
security number, payment history, account number(s), and
name(s) and address(s) of health care provider(s) and/or
health plan(s).
