Travis, I hope that I understand your question correctly: I believe you are asking about the dual roles that an employer may have under HIPAA. In your situation, you have a third HIPAA role as a covered provider or a health plan as well (I wasn't sure which from the name "Cook Children's Health Care System".)
As William pointed out, your role as a covered provider or covered health plan is independent of your role as an employer with a group health plan. Below are the three variations to that relationship. I hope this helps you sort out your HIPAA obligations as an employer. It does not conflict with William's conclusions on this issue. Under ERISA, an employer that offers a health plan to employees has two separate legal identities: (1) as an employer acting as a group health plan "sponsor"; and (2) as an employer acting as a group health plan. HIPAA does not apply to employer sponsors. HIPAA does apply to fully funded and self-administered employer group plans. The only exception is for self-administered employer group plans that have less than 50 participants. Three variations: (1) If the employer, acting as a sponsor, has a fully funded employer health plan, then only the health plan(s) with which the sponsor contracts must comply with the HIPAA standards. If an employer sponsor chooses to conduct nonstandard enrollment/disenrollment and premium transactions, an employer's contracted health plans are free to accept these transactions. If the employer sponsor chooses to conduct the HIPAA ASC X12 834 enrollment/disenrollment or 820 premium transaction with its contracted health plans, then these health plans must conduct these transactions in accordance with HIPAA. (2) If the employer, acting as a sponsor, is also the administrator of its self-administer health plan, then the employer's self-administered health plan must comply with the HIPAA standards. If the employer sponsor chooses to conduct nonstandard enrollment and premium transactions with its own self-administered health plan, that plan is free to accept these transactions. If the employer sponsor chooses to conduct the HIPAA ASC X12 834 enrollment/disenrollment or 820 premium transaction with its own self-administered health plan, then the self-administered health plan must conduct these transactions in accordance with HIPAA. (3) If the employer, acting as a sponsor, is also the administrator of its self-administered health plan, and the employer's self-administered plan has contracted with a third party administer (TPA) to administer that health plan on its behalf, then the TPA must comply with the HIPAA standards (for any contracted covered functions.) In this scenario, the TPA is a business associate of the employer's self-administered health plan and must do what the health plan must do under HIPAA. If an employer sponsor chooses to conduct nonstandard enrollment/disenrollment and premium transactions, a contracted TPA is free to accept these transactions. If the employer sponsor chooses to conduct the HIPAA ASC X12 834 enrollment/disenrollment or 820 premium transaction with its contracted TPA, then the TPA must conduct these transactions in accordance with HIPAA. However, employer sponsors and their health plans should consider the benefits of conducting enrollment and premium payment transactions in accordance with the HIPAA health care transaction and data standards. Most health plans, software vendors, clearinghouses, providers and other trading partners in the health care community will be supporting these standards and will likely prefer to do electronic business in accordance with HIPAA requirements. If Cook Children's Health Care System is a health plan, then it must have the capacity to conduct the 834 and 820 anyway for any sponsor that may wish to use those transactions. If you contract with a Medicaid as a managed care health plan, then the Medicaid is required to send you the 834 and the 820. Regards, Kathleen Connor Senior Consultant Fox Systems, Inc. -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED] Sent: Thursday, March 20, 2003 4:33 AM To: WEDI SNIP Transactions Workgroup List Subject: Re: Covered Entity as an Employer Travis, even though Cook Children's is a covered entity provider, when you enroll your own employees in an insurance program you are acting in the role of an ordinary employer. There's no requirement for you (as an employer) to use the standard 834 - even though every insurance plan must be prepared to accept it if any employer wishes to use it. There's nothing to prevent you from exchanging any mutually agreeable non-standard format of enrollment data with your health plan - which may simply be your current benefit eligibility transaction format. I'll warn you, though, that my "role-based" interpretation of the rule is fairly controversial. I've even been called irresponsible for proffering this opinion on the 834. Folks will say a provider is a provider, and hence a covered entity, no matter what it's doing, and that it has to follow the letter of the rule - no matter what. Even if it doesn't make any sense. What's so different between what Cook Children's does with respect to enrolling its employees from, say, General Motors, who obviously isn't mandated by HIPAA to use the 834? The enrollment of your own employees is an employer function that has absolutely nothing to do with your provider obligations under HIPAA to protect patient privacy or to use the prescribed standard transactions for electronic patient claims, remittances, inquiries, etc. It still doesn't convince the skeptics when you tell them � 162.900(a) doesn't even include the Enrollment or 834 (Subpart O) as a transaction required of providers - you would think that would settle the issue once and for all! All I can say is: don't take my word for it; you'll have to hunker down (expensively) with your legal counsel to see if it makes sense for you to risk "skirting" the law by not using the 834 to enroll your employees in the health plan. It's interesting that folks can make a really liberal interpretation of "role" when it's their own ox being gored. The TCS rule makes it pretty darned clear that clearinghouses must always produce standard transactions for transmission to a payer, unless that payer has a business associate agreement with the CH - and has explicitly contracted to have non-standard (say, paper) produced for it; see � 162.930. In this case, though, these folks say that clearinghouses can decide on a moment-by-moment basis whether they're acting in the "role" of a clearinghouse covered entity. So if the CH would rather just "dump" claim transactions to paper because the occasion suits it, the CH can just sprinkle magic dust on itself, taking away its covered entity status for that moment it does the "dumping." William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Travis Turman" <[EMAIL PROTECTED]> To: "WEDI SNIP Transactions Workgroup List" <[EMAIL PROTECTED]> Sent: Wednesday, 19 March, 2003 05:39 PM Subject: Covered Entity as an Employer Since a covered entity is also an employer, do enrollment/disenrollment transactions between the covered entity and the insurance carrier used to provide their employee health benefit plan need to use the standard 834 transaction? Travis L. Turman System Analyst Information Services Phone: (817) 870-6490 Pager: (817) 669-0664 E-mail: [EMAIL PROTECTED] ***************************************************************** Cook Children's Health Care System --- 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/. These listservs should not be used for commercial marketing purposes or discussion of specific vendor products and services. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. 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