For purposes of this part, the following definitions apply:
Code set means any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. A code set includes the codes and the descriptors of the codes.
Code set maintaining organization means an organization that creates and maintains the code sets adopted by the Secretary for use in the transactions for which standards are adopted in this part.
Data condition means the rule that describes the circumstances under which a covered entity must use a particular data element or segment.
Data content means all the data elements and code sets inherent to a transaction, and not related to the format of the transaction. Data elements that are related to the format are not data content.
Data element means the smallest named unit of information in a transaction.
Data set means a semantically meaningful unit of information exchanged between two parties to a transaction.
Descriptor means the text defining a code.
Designated standard maintenance organization (DSMO)
means an organization designated by the Secretary under § 162.910(a)
Direct data entry means the direct entry of data (for example, using dumb terminals or web browsers) that is immediately transmitted into a health plan's computer.
Format refers to those data elements that provide or control the enveloping or hierarchical structure, or assist in identifying data content of, a transaction.
HCPCS stands for the Health [Care Financing Administration] Common Procedure Coding System.
Maintain or maintenance refers to activities necessary to support the use of a standard adopted by the Secretary, including technical corrections to an implementation specification, and enhancements or expansion of a code set. This term excludes the activities related to the adoption of a new standard or implementation specification, or modification to an adopted standard or implementation specification.
Maximum defined data set means all of the required data elements for a particular standard based on a specific implementation specification.
Operating rules means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted for purposes of this part.
Segment means a group of related data elements in a transaction.
Stage 1 payment initiation means a health plan's order, instruction or authorization to its financial institution to make a health care claims payment using an electronic funds transfer (EFT) through the ACH Network.
Standard transaction means a transaction that complies with an applicable standard and associated operating rules adopted under this part.
§ 162.103, Nt.
[65 FR 50367
, Aug. 17, 2000, as amended at 68 FR 8374
, Feb. 20, 2003; 74 FR 3324
, Jan. 16, 2009; 76 FR 40495
, July 8, 2011; 77 FR 1589
, Jan. 10, 2012]
Effective Date Note:
At 77 FR 54719
, Sept. 5, 2012, § 162.103
was amended by adding the definitions of “Controlling health plan (CHP),” “Covered health care provider,” and “Subhealth plan (SHP)”, effective Nov. 5, 2012. For the convenience of the user, the added text is set forth as follows:
Controlling health plan (CHP) means a health plan that—
(1) Controls its own business activities, actions, or policies; or
(2)(i) Is controlled by an entity that is not a health plan; and
(ii) If it has a subhealth plan(s) (as defined in this section), exercises sufficient control over the subhealth plan(s) to direct its/their business activities, actions, or policies.
Covered health care provider
means a health care provider that meets the definition at paragraph (3) of the definition of “covered entity” at § 160.103
Subhealth plan (SHP) means a health plan whose business activities, actions, or policies are directed by a controlling health plan.