Covered Entity (Health Care) Law & Legal Definition


Covered entity means an organization that routinely handles protected health information. The US Health Insurance Portability and Accountability Act (HIPAA) defines covered entity as health plans, health care clearing houses, and health care providers who electronically transmit health information in connection with transactions concerning billing and payment for services or insurance coverage. For example, hospitals, academic medical centers, physicians, and other health care providers who transmit information relating to claims transaction directly or through an intermediary electronically to a health plan are covered entities. Institutions, organizations, or persons can also be covered entities.

Covered entity can be a federally-qualified health center, an entity receiving a grant under section 340A [42 USCS § 256a], a family planning project receiving a grant or contract under section 1001 [42 USCS § 300], an entity receiving a grant relating to categorical grants for outpatient early intervention services for HIV disease under subpart II of part C of title XXVI [42 USCS §§ 300ff-51, a State-operated AIDS drug purchasing assistance program receiving financial assistance, a black lung clinic receiving funds under section 427(a) of the Black Lung Benefits Act [30 USCS § 937(a)], a comprehensive hemophilia diagnostic treatment center receiving a grant under section 501(a)(2) of the Social Security Act [42 USCS § 701(a)(2)], a Native Hawaiian Health Center receiving funds under the Native Hawaiian Health Care Act of 1988 [42 USCS §§ 11701 et seq.], an urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act [25 USCS §§ 1651 et seq.], any entity receiving assistance under title XXVI [42 USCS §§ 300ff-11 et seq.], an entity receiving funds relating to treatment of sexually transmitted diseases and tuberculosis under section 318 [42 USCS § 247c] or section 317(j)(2) [42 USCS § 247b(j)(2)], a children's hospital excluded from the Medicare prospective payment system or a free-standing cancer hospital excluded from the Medicare prospective payment system, an entity that is a critical access hospital or a rural referral center, or a sole community hospital [ 42 USCS § 256b(a)(4)].