Under HIPAA, what is the entity that processes healthcare claims and performs related functions for a health plan?

Question

Options

• APolicy Advisory Group
• BThird Party Administrator
• CJoint Commission on Accreditation of Healthcare Organizations
• DPlan Sponsor

• A
  4% (1)
• B
  88% (22)
• C
  4% (1)
• D
  4% (1)

Explanation

Under HIPAA, a Third Party Administrator (TPA) is the entity that processes healthcare claims and performs related administrative functions on behalf of a health plan - this is a defined role under HIPAA's covered entity framework. A Policy Advisory Group (A) is not a HIPAA-defined entity and has no claim-processing role. The Joint Commission on Accreditation of Healthcare Organizations (C) is an accreditation body that evaluates healthcare quality standards, not a claims processor. A Plan Sponsor (D) is the employer or organization that establishes or maintains a health plan, not the one processing its claims.

Memory tip: Think "Third Party" = the middleman between the patient/provider and the health plan - TPAs sit in the middle and handle the paperwork (claims), making them the processing entity HIPAA specifically addresses.

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