Health Care Operations

Date of Publication:

3/13/2019

Definition:

Any of the following activities of the covered entity to the extent that the activities are related to covered functions: Conducting quality assessment and improvement activities, including outcomes evaluation and development of clinical guidelines, if obtaining general knowledge is not the primary purpose of any studies resulting from such activities; patient safety activities as defined in Section 3.20 of Title 42, CFR; population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting of health care providers and patients with information about treatment alternatives; and related functions that do not include treatment. Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance, conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals, accreditation, certification, licensing, or credentialing activities. Enrollment, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care (including stop-loss insurance and excess of loss insurance). Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection, and compliance programs. Business planning and development, such as conducting cost management and planning related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment, or coverage policies. Business management and general administrative activities of the entity including, but not limited to: Management activities relating to implementation of and compliance with the requirements of this issuance. Customer service, if PHI is not disclosed except as otherwise permitted by this issuance. Resolution of internal grievances. The sale, transfer, merger, or consolidation of all or part of the covered entity with another covered entity, or an entity that following such activity will become a covered entity and due diligence related to such activity. Creating de-identified health information or a limited data set, and fundraising for the benefit of the covered entity.