Step 1: Select the category that best describes your organization
Health Care Provider
Anyone who furnishes, bills, or receives payment for health care services.
Examples:
doctors’ offices (including family medicine, pediatrics),
dental clinics (e.g., a dental office submitting electronic ADA claims),
pharmacies dispensing prescriptions,
physical therapy practices, or any medical clinic that bills for care.
Health Care Clearinghouse
An entity that processes or translates health information between nonstandard formats and standard HIPAA‐required formats.
Examples:
companies that convert paper lab results into electronic claims,
billing services that reformat provider invoices into ANSI X12 EDI format,
agencies that receive nonstandard insurance data and output a HIPAA‐compliant transaction.
Private Benefit Plan
A plan established by a private employer or group to provide or pay for medical care.
Examples:
employer-sponsored group health plans (like your company’s medical plan),
self-insured plans administered internally,
Medigap supplemental plans offered to retirees,
HMOs organized by private corporations.
Government-Funded Program
A federally funded plan that provides or pays for health care.
Examples:
Medicare, Medicaid or CHIP,
TRICARE/CHAMPVA for military families,
Indian Health Service clinics,
Federal Employees Health Benefits Program,
state high-risk pools or other government-run programs.
Start Questionnaire
Health Care Provider
Q1: Do you furnish, bill, or receive payment for health care in the normal course of business?
Do you regularly provide medical or dental services (for example, exams, treatments, prescriptions) and then bill a patient or insurance company (whether by paper or electronically) for those services as part of your day-to-day operations?
Yes
No
Next →
Health Care Provider
Q2: Do you transmit any “covered transactions” electronically?
Covered transactions include electronic claims, eligibility inquiries, claim status updates, payment/eligibility remittance advices—all in CMS/HHS-mandated EDI formats.
Yes
No
Finish
Health Care Clearinghouse
Q1: Do you process or facilitate the processing of health information from nonstandard to standard format (or vice versa)?
Do you take health data or medical records in a non-HIPAA format (for example, paper charts, custom spreadsheets, or proprietary files) and convert them into the official HIPAA electronic format (like the standard ANSI X12 transactions), or do you take HIPAA-compliant electronic data and convert it back into a nonstandard form for another party?
Yes
No
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Health Care Clearinghouse
Q2: Do you perform that function for another legal entity (for example, a health care provider or health plan)?
Do you convert or reformat health information on behalf of another organization—such as providing that service to a doctor’s office, hospital, or health insurance plan?
Yes
No
Finish
Private Benefit Plan
Q1: Is the plan an individual or group plan (or combination) that provides or pays for the cost of medical care?
Is this an insurance plan or benefit program, either for a single person or a group of people, that covers or pays for medical services and treatments?
Yes
No
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Private Benefit Plan
Q2: Is the plan a group health plan (meaning multiple participants are covered under one policy)?
Is this a health insurance plan or benefit program that covers more than one person under the same policy, such as an employer-sponsored health plan where all employees are included?
Yes
No
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Private Benefit Plan
Q3: For that group health plan, does it meet both of these criteria?
• Fewer than 50 participants total
• Administered entirely by the employer (no third-party administrator)
Yes
No
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Private Benefit Plan
Q4: Is the plan a health insurance issuer (an entity that underwrites or sells health insurance policies)?
Is your organization in the business of creating, underwriting, or selling health insurance policies—meaning you design coverage plans, set premiums, and issue those policies to individuals or groups?
Yes
No
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Private Benefit Plan
Q5: Is the plan an issuer of a Medicare supplemental policy (Medigap)—that is, sold to individuals to fill “gaps” in Medicare coverage?
Does your organization issue Medigap (Medicare Supplemental) policies—meaning extra insurance plans sold to fill coverage gaps that Original Medicare doesn’t pay?
Yes
No
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Private Benefit Plan
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Private Benefit Plan
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Private Benefit Plan
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Private Benefit Plan
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Private Benefit Plan
Q10: Does the plan provide only excepted benefits (benefits not subject to HIPAA’s group health plan requirements)?
(Examples of excepted benefits: dental-only plans, vision-only plans, specific disease or limited indemnity policies.)
Yes
No
Finish
Government-Funded Program
Q1: Is the program one of these government health plans?
• Medicare (for seniors and certain disabled individuals)
• Medicaid/CHIP (state health plans for low-income families and children)
• TRICARE/CHAMPVA (military/Veterans Administration benefits)
• Federal Employees Health Benefits Program (for federal government workers)
• Indian Health Service (health care for Native American communities)
• Other federally-funded health plan (e.g., state high-risk pool, certain public health initiatives)
Yes
No
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Government-Funded Program
Q2: Is the program an individual or group plan that provides or pays for the cost of medical care?
(For example, a state-run Medicaid managed care plan or a tribal health plan covering a community.)
Yes
No
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Government-Funded Program
Q3: Is the program specifically a state high-risk pool designed to cover individuals unable to obtain private insurance?
State high-risk pools are publicly funded programs that provide health coverage to individuals who have been denied private insurance due to pre-existing conditions or other high-risk factors.
Yes
No
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Government-Funded Program
Q4: Is the program organized as a Health Maintenance Organization (HMO)?
(An HMO is an integrated network of doctors and hospitals under one plan—for example, a state-run HMO for Medicaid recipients.)
Yes
No
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Government-Funded Program
Q5: Is the principal activity of the program providing health care directly to individuals?
(Examples: a county public health clinic, a VA hospital serving veterans, or an Indian Health Service facility.)
Yes
No
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Government-Funded Program
Q6: Is the principal activity making grants to fund the direct provision of health care?
(For example, a state agency that awards grants to community health centers—but does not itself provide care.)
Yes
No
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Government-Funded Program
Q7: Is the principal purpose of the program something other than providing or paying the cost of health care?
(Examples: a prison system providing meals and security, or a scholarship fund for students—neither directly provides or pays for medical care.)
Yes
No
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Government-Funded Program
Q8: Does the program provide only excepted benefits?
(Examples: dental-only, vision-only, certain limited indemnity programs—benefits that are not subject to full HIPAA group health plan rules.)
Yes
No
Finish