Corporate Compliance

Q&A: Small providers and HIPAA

Compliance Monitor, September 16, 2009

Q&A: What defines a small provider and are they exempt from HIPAA?
 
The term “small providers” originates in the Administrative Simplification Compliance Act (ASCA), the law which requires those providers/submitters who bill Medicare to submit only electronic claims to Medicare on October 16, 2003 in the HIPAA format. However, ASCA does provide an exception to the Medicare electronic claims submission requirements to “small providers”. ASCA defines a small provider or supplier as: a provider of services with fewer than 25 full-time equivalent employees or a physician, practitioner, facility or supplier (other than a provider of services) with fewer than 10 full-time equivalent employees.
 
It is important to keep in mind that this provision does not preclude providers from submitting paper claims to other health plans. In addition, if a provider transmits any of the designated transactions electronically, it is subject to the HIPAA Administrative Simplification requirements regardless of size.
 
This Q&A is adapted from the CMS FAQ website page. To see this and other FAQs click here.

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