What is the definition of a HIPAA-covered entity?

by | Jul 3, 2023 | HIPAA News and Advice

A HIPAA-covered entity refers to a healthcare provider, health plan, or healthcare clearinghouse that transmits, receives, or maintains individually identifiable health information in electronic form, falling under the regulatory jurisdiction of HIPAA and its related privacy and security rules. Such entities play fundamental roles in the delivery of healthcare services, the administration of health plans, and the facilitation of electronic health information exchange.

Terms Related to a HIPAA-Covered EntityDefinition
HIPAA-Covered EntitiesSpecific entities involved in the healthcare ecosystem that handle individually identifiable health information.
Healthcare Entity CategoriesThree main categories: Healthcare Providers, Health Plans, and Healthcare Clearinghouses.
Healthcare ProvidersCovers medical professionals, clinics, hospitals, and allied healthcare practitioners.
Generate, maintain, and transmit electronic health information for patient care and treatment.
Health PlansInclude insurance companies, HMOs, and government programs paying for medical care.
Manage financial aspects by processing claims, assessing medical necessity, and overseeing reimbursements.
Healthcare ClearinghousesServe as intermediaries converting non-standard health information formats into standard electronic transactions.
Streamline communication between healthcare providers and health plans.
FocusInvolvement with individually identifiable health information.
Individually Identifiable Health InformationData linkable to a specific individual, related to their health status, healthcare provision, or payment for healthcare.
ScopeCovers all formats and mediums where health information is maintained, including electronic and non-electronic forms.
Digitization ImpactReflects the importance of safeguarding electronic health information due to the growing digitization of healthcare data.
Challenges AddressedAddresses challenges such as data breaches, unauthorized access, and identity theft
Role of Covered EntitiesMaintaining confidentiality, integrity, and availability of patient data.
ImportanceEnsure HIPAA compliance and protect patient data privacy and security.
Table: Definition of Terms Related to HIPAA-Covered Entities

A HIPAA-covered entity falls under one of three distinct categories: healthcare providers, health plans, and healthcare clearinghouses. Each of these categories possesses distinct functions, but a common thread among them is their engagement with individually identifiable health information in electronic form. This not only includes the conventional medical records maintained by healthcare providers but also extends to the digital realm where electronic health records (EHRs), billing information, and other sensitive health data are processed, stored, and transmitted. The definition serves as a boundary marker, demarcating the entities that are under HIPAA regulations and those that may be exempt from its stringent provisions. Healthcare providers include many professionals, institutions, and organizations that offer medical services to patients. This category includes hospitals, clinics, physicians, dentists, psychologists, and allied healthcare professionals. These providers not only render medical treatment but also generate, maintain, and transmit health information for care coordination, diagnosis, treatment planning, and continuity of care. The extension of HIPAA regulations to these entities seeks to safeguard the privacy and security of patients’ electronic health information, promoting trust between individuals and their healthcare providers.

Health plans, the second category of HIPAA-covered entities, include insurance companies, health maintenance organizations (HMOs), and government programs that provide or pay for medical care. This category represents the financial support of healthcare services, administering reimbursements and bearing financial responsibility for healthcare expenditures. Health plans amass and process health information, not solely for claims adjudication but also to assess the medical necessity of treatments, manage utilization, and enable population health management initiatives. The inclusion of health plans within the scope of HIPAA shows the significance of data protection across the lifecycle of healthcare interactions, from the initial patient encounter to the reimbursement processes. The third category of HIPAA-covered entities is healthcare clearinghouses. These entities serve as intermediaries, facilitating the transformation of non-standard health information formats into standard electronic transactions. This includes the conversion of paper-based claims into electronic formats and vice versa, enabling seamless communication between healthcare providers and health plans. While clearinghouses do not generate protected health information themselves, they play a role in data harmonization and transmission. Their inclusion within the scope of HIPAA reflects the holistic approach taken by the legislation, acknowledging the entire ecosystem involved in health data exchange.

The heart of the HIPAA-covered entity definition lies in its association with individually identifiable health information. This refers to any data that can be linked to a specific individual and pertains to their past, present, or future health status, provision of healthcare, or payment for healthcare services. While the definition covers electronic health information, the scope extends to any form or medium in which this information is maintained. This embraces not only electronic health records and billing systems but also written or spoken communications containing patient data. This approach reflects the legislation’s intent to create a framework for safeguarding patient information regardless of its manifestation.

The incorporation of electronic health information within the scope of HIPAA stems from the recognition of the growing digitization of healthcare data and the potential risks of HIPAA violations associated with its transmission and storage. The digitization of health information has undoubtedly accelerated the pace of healthcare delivery, enabling rapid information sharing and facilitating clinical decision-making. However, this digital transformation has also raised concerns about data breaches, unauthorized access, and identity theft. By covering individually identifiable health information in electronic form, HIPAA addresses these evolving challenges and establishes a cohesive regulatory framework for maintaining the confidentiality, integrity, and availability of patient data.


A HIPAA-covered entity, which may be under one of these categories, healthcare providers, health plans, and healthcare clearinghouses, is engaged in the electronic processing, maintenance, and transmission of individually identifiable health information. The definition serves as a basis in the regulatory framework, extending the protective umbrella of HIPAA regulations to cover digital health data. By understanding the definition of HIPAA-covered entities and their association with electronic health information, healthcare professionals can handle data privacy, security, and interoperability with a heightened sense of responsibility and HIPAA compliance.

HIPAA Covered Entity Topics

What is the definition of a HIPAA-covered entity?
How does an organization determine if it is a HIPAA-covered entity?
Are all healthcare providers considered HIPAA-covered entities?
What obligations does an entity covered by HIPAA have concerning patient data?
Do insurance companies fall under the category of entities covered by HIPAA?
What is a covered entity under HIPAA?
Who would not be considered a covered entity under HIPAA?
Is an employer a covered entity under HIPAA?
Who should HIPAA complaints be directed to within the covered entity?
What are the penalties for a HIPAA-covered entity that breaches patient confidentiality?
Are health technology companies automatically considered HIPAA-covered entities?
What distinguishes a HIPAA entity from non-covered entities?
Can a HIPAA-covered entity share medical records with another such entity without patient consent?
How often should HIPAA-covered entities review their compliance procedures?
What types of training must employees of an entity covered by HIPAA undergo?
How do entities covered by HIPAA handle data breaches?
What is the role of a privacy officer in a HIPAA-covered entity?
Are dental practices considered HIPAA-covered entities?
Can a patient sue a HIPAA-covered entity for a data breach?
How are HIPAA-covered entities audited for compliance?
What are the reporting obligations of a HIPAA entity in case of data exposure?
How do third-party vendors interact with HIPAA-covered entities?
Can a business associate be considered a HIPAA-covered entity?
How should a HIPAA entity respond to unauthorized access to protected health information?
What security measures must entities covered by HIPAA implement?
Are there exemptions for certain types of entities covered by HIPAA?
How long must a HIPAA-covered entity retain medical records?
What patient rights are recognized by entities covered by HIPAA concerning their personal data?
Are telemedicine platforms typically classified as HIPAA-covered entities?
What distinguishes business associates from HIPAA-covered entities?
How can patients file complaints against a HIPAA entity?
What is the significance of the Notice of Privacy Practices for a HIPAA-covered entity?
How do international medical tourism practices intersect with HIPAA-covered entities?
Are there specific encryption standards that a HIPAA-covered entity must adhere to?
How do federal and state laws regarding patient privacy relate to HIPAA-covered entities?
How do HIPAA-covered entities handle minor patient information?
Are pharmacies and drug stores universally categorized as HIPAA-covered entities?
How can a HIPAA-covered entity ensure compliance when integrating new technologies?
What are the key differences between a HIPAA-covered entity and a HIPAA business associate?
Are research institutions always considered HIPAA-covered entities?
What are the boundaries of marketing activities for an entity covered by HIPAA?
Can cloud service providers be classified as HIPAA-covered entities?
How should a HIPAA entity prepare for an official audit or review?
What documentation is essential for a HIPAA-covered entity’s compliance processes?
How often do regulations impacting HIPAA-covered entities get updated?
Do educational institutions fall under the scope of entities covered by HIPAA?
How do mobile health apps and digital health tools intersect with HIPAA-covered entities?
What is the role of electronic health record systems in a HIPAA-covered entity?
How does the Health Information Exchange (HIE) network impact HIPAA-covered entities?
Are mental health professionals bound by the same rules as other HIPAA-covered entities?
How do mergers and acquisitions impact the status of a HIPAA-covered entity?
Can patients access all their health data held by a HIPAA-covered entity?
Are billing and invoicing data handled differently by entities covered by HIPAA than medical data?
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