Treatment

Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.

Payment

Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits, and furnish or obtain reimbursement for health care delivered to an individual and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual.

Health Care Operations

Health care operations are any of the following activities:

  • Quality assessment and improvement activities, including case management and care coordination
  • Competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation
  • Conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs
  • Specified insurance functions, such as underwriting, risk rating, and reinsuring risk
  • Business planning, development, management and administration
  • Business management and general administrative activities of the entity, including but not limited to; de-identifying protected health information, creating a limited data set, and certain fundraising for the benefit of the covered entity