Who qualifies as a covered entity under HIPAA?

A covered entity under HIPAA refers specifically to certain types of organizations or individuals that handle protected health information (PHI). Healthcare providers that engage in the electronic transmission of health information for purposes related to treatment, payment, or healthcare operations are classified as covered entities. This includes doctors, clinics, hospitals, psychologists, nursing homes, and pharmacies, provided they engage in these electronic transactions.

This designation is significant because covered entities are subject to HIPAA regulations, which enforce standards for the privacy and security of PHI. To qualify, these providers must be involved in the standard electronic transactions as defined by HIPAA, which include billing, eligibility checks, and claim submissions.

While insurance companies that manage health records could also qualify as covered entities—since they often transmit health information electronically—it is the healthcare providers who transmit health information electronically that is directly referenced in this context. Patients themselves do not meet the criteria for covered entities under HIPAA because they do not manage or transmit PHI; rather, they are the individuals whose health information is protected. Similarly, the employees of a healthcare organization do not individually qualify as covered entities, as the organization itself is the entity that protects and manages the health information.