PRIA, Government Policy, Made Personal

Summary

Defines key words used in these rules. Code set: collections of codes used to record health data, like diagnosis or procedure codes. Health care clearinghouse: an organization that turns nonstandard health data into standard formats or helps with that. Health care provider: doctors, hospitals, clinics, and anyone who gives health care services or supplies. Health information: any spoken or recorded information made or received by providers, plans, public health authorities, employers, life insurers, schools, or clearinghouses that is about a person’s health, care, or payment for care. Health plan: any individual or group plan that pays for medical care, including group plans (if they have 50 or more participants or are run by someone other than the employer), insurers, HMOs, Medicare Parts A–D, Medicaid, certain supplemental and long‑term care policies, military and veterans programs, Indian Health Service, the Federal Employees Health Benefit Plan, and similar programs. Individually identifiable health information: health information (including basic demographic data) created or received by providers, plans, employers, or clearinghouses that identifies a person or could reasonably be used to identify them. Standard: a data element or transaction that meets all rules and implementation specs set by the Secretary. Standard setting organization: an ANSI‑accredited group that develops standards (for example, NCPDP). Operating rules: business rules needed for electronic health exchanges that are not covered by a standard or its implementation specs.

Title 42, §1320d

The Public Health and Welfare, Source: USLM XML via OLRC

For purposes of this part:

(1)Code set

The term “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.

(2)Health care clearinghouse

The term “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.

(3)Health care provider

The term “health care provider” includes a provider of services (as defined in section 1395x(u) of this title), a provider of medical or other health services (as defined in section 1395x(s) of this title), and any other person furnishing health care services or supplies.

(4)Health information

The term “health information” means any information, whether oral or recorded in any form or medium, that—

(A)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

(B)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.

(5)Health plan

The term “health plan” means an individual or group plan that provides, or pays the cost of, medical care (as such term is defined in section 300gg–91 of this title). Such term includes the following, and any combination thereof: (A)

(B)A health insurance issuer (as defined in section 300gg–91(b) of this title).

(C)A health maintenance organization (as defined in section 300gg–91(b) of this title).

(D)Parts A, B, C, or D of the Medicare program under subchapter XVIII.

(E)The medicaid program under subchapter XIX.

(F)A Medicare supplemental policy (as defined in section 1395ss(g)(1) of this title).

(G)A long-term care policy, including a nursing home fixed indemnity policy (unless the Secretary determines that such a policy does not provide sufficiently comprehensive coverage of a benefit so that the policy should be treated as a health plan).

(H)An employee welfare benefit plan or any other arrangement which is established or maintained for the purpose of offering or providing health benefits to the employees of 2 or more employers.

(I)The health care program for active military personnel under title 10.

(J)The veterans health care program under chapter 17 of title 38.

(K)The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), as defined in section 1072(4) of title 10.

(L)The Indian health service program under the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.).

(M)The Federal Employees Health Benefit Plan under chapter 89 of title 5.

(6)Individually identifiable health information

The term “individually identifiable health information” means any information, including demographic information collected from an individual, that—

(A)is created or received by a health care provider, health plan, employer, or health care clearinghouse; and

(i)identifies the individual; or

(ii)with respect to which there is a reasonable basis to believe that the information can be used to identify the individual.

(7)Standard

The term “standard”, when used with reference to a data element of health information or a transaction referred to in section 1320d–2(a)(1) of this title, means any such data element or transaction that meets each of the standards and implementation specifications adopted or established by the Secretary with respect to the data element or transaction under sections 1320d–1 through 1320d–3 of this title.

(8)Standard setting organization

The term “standard setting organization” means a standard setting organization accredited by the American National Standards Institute, including the National Council for Prescription Drug Programs, that develops standards for information transactions, data elements, or any other standard that is necessary to, or will facilitate, the implementation of this part.

(9)Operating rules

The term “operating rules” means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted for purposes of this part.

Notes & Related Subsidiaries

Editorial Notes

References in Text

The Indian Health Care Improvement Act, referred to in par. (5)(L), is Pub. L. 94–437, Sept. 30, 1976, 90 Stat. 1400, which is classified principally to chapter 18 (§ 1601 et seq.) of Title 25, Indians. For complete classification of this Act to the Code, see

Short Title

note set out under section 1601 of Title 25 and Tables.

Prior Provisions

A prior section 1171 of act Aug. 14, 1935, was classified to section 1320c–20 of this title prior to repeal by Pub. L. 97–35.

Amendments

2010—Par. (9). Pub. L. 111–148 added par. (9). 2009—Par. (5)(D). Pub. L. 111–5 substituted “C, or D” for “or C”. 2001—Par. (5)(D). Pub. L. 107–105 substituted “Parts A, B, or C” for “Part A or part B”.

Statutory Notes and Related Subsidiaries

Effective Date

of 2010 Amendment Pub. L. 111–148, title I, § 1105, Mar. 23, 2010, 124 Stat. 154, provided that: “This subtitle [subtitle B (§§ 1101–1105) of title I of Pub. L. 111–148, enacting subchapter I of chapter 157 of this title, amending this section and section 1320d–2 and 1395y of this title, enacting provisions set out as a note under section 1320d–2 of this title, and amending provisions set out as a note under this section] shall take effect on the date of enactment of this Act [Mar. 23, 2010].” Purpose Pub. L. 104–191, title II, § 261, Aug. 21, 1996, 110 Stat. 2021, as amended by Pub. L. 111–148, title I, § 1104(a), Mar. 23, 2010, 124 Stat. 146, provided that: “It is the purpose of this subtitle [subtitle F (§§ 261–264) of title II of Pub. L. 104–191, enacting this part, amending section 242k and 1395cc of this title, and enacting provisions set out as a note under section 1320d–2 of this title] to improve the Medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], the medicaid program under title XIX of such Act [42 U.S.C. 1396 et seq.], and the efficiency and effectiveness of the health care system, by encouraging the development of a health information system through the establishment of uniform standards and requirements for the electronic transmission of certain health information and to reduce the clerical burden on patients, health care providers, and health plans.”

§1320d Definitions