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HIPAA and the Legal Medical Record
Terms in this set (22)
Acknowledgment of Receipt of Notice of Privacy
Form accompanying a covered entity's Notice of Privacy Practices; covered entities must make a good-faith effort to have patients sign the acknowledgment.
Document signed by a patient that permits release of particular medical information under the specific stated conditions.
A company that converts,for a fee, non standard data formats into HIPAA standard transactions and transmits the data to health plans; or also handles the reverse process, changing HIPAA formatted transactions from health plans into nonstandard formats for providers.
A medical practice's written plan for (a) the appointment of a compliance officer and committee, (b) a code of conduct for physicians' business arrangements and employees' compliance, (c) training plans, (d) properly prepared and updated coding tools such as job reference aids, encounter forms, and documentation templates, (e) rules for prompt identification and refunding of overpayments, and (f) ongoing monitoring and auditing of claim preparation.
The systematic, logical, and consistent recording of a patient's health status-history, examinations, tests, results of treatments, and observations-in chronological order in a patient's medical record.
Electronic Health Records (EHR)
A running collection of health information that provides immediate electronic access by authorized users.
Intentional deceptive act to obtain a benefit.
Health Insurance Portability and Accountability Act (HIPAA)
Federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.
HIPAA Electronic Health Care Transactions and Code Sets (TCS)
The HIPAA rule governing the electronic exchange of health information.
HIPAA Privacy Rule
Law that regulates the use disclosure of patients' protected health information (PHI)
HIPAA Security Rule
Law that requires covered entities to establish administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of health information.
Files that contain the documentation of patients' medical history, record of care, progress notes, correspondence, and related billing/financial information.
Minimum necessary standard
Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of disclosure.
National Plan and Provider Enumeration System (NPPES)
A system set up by HHS which processes applications for NPIs, assigns them, and then stores the data and identifying numbers for both health plans and providers.
National Provider Identifier (NPI)
Under HIPAA, unique 10-digit identifier assigned to each provider by the National Provider System; replaces both the UPIN and Medicare PIN.
Notice of Privacy Practices (NPP)
A HIPAA-mandated description of a covered entity's principles and procedures related to the protection of patients' health information.
Office of Civil Rights (OCR)
Government agency that enforces the HIPAA Privacy Act.
Protected Health Information (PHI)
Individually identifiable health information that is transmitted or maintained by electronic media.
A practice policy that governs which information from patients' medical records is to be stored, for how long it is to be retained, and the storage medium to be used.
A order of a court for a party to appear and testify in a court of law.
Subpoena duces tectum
An order of a court directing a party to appear, to testify, and to bring specified documents or items.
Treatment, payment, and operations (TPO)
Health care treatment, payment, and operations; under HIPAA, patients' protected health information may be shared for TPO.
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