To perform one or more operations on information for conducting activities related to coverage under a program or policy.

To perform one or more operations on information for provision of additional clinical evidence in support of a request for coverage or payment for health services.

To perform one or more operations on information for conducting prior authorization or predetermination of coverage for services.

To perform one or more operations on information used for conducting administrative activities to improve health care quality.

To perform one or more actions on information used for conducting administrative and contractual activities by or on behalf of organizational entities responsible for delivery of an individual's benefits in a healthcare program, health plan or insurance. Explicitly excludes the use of information to organize the delivery of health care for care coordination and case management, or to provide healthcare treatment.

                       Usage Note: Examples of activities conducted under this purpose of use: provider profiling, risk adjustment, underwriting, fraud and abuse, quality improvement population health and care management. Aligns with HIPAA Operation POU minus coordination of care or other treatment related activities. Similar to the description in SAMHSA Confidentiality of Substance Use Disorder Patient Records Supplemental notice of proposed rulemaking.

                    
                       Map: Maps to ISO 14265 Classification Term  "Administration of care for an individual subject of care" described as "To inform persons or processes responsible for enabling the availability of resources or funding or permissions for providing health care services to the subject of care."

                    However, this classification term is described as activities, i.e., "to inform persons" or "to inform processes" rather than the rationale for performing actions/operations on information related to the activity.

To perform one or more actions on information in order to organize the provision and case management of an individual’s healthcare, including: Monitoring a person's goals, needs, and preferences; acting as the communication link between two or more participants concerned with a person's health and wellness; organizing and facilitating care activities and promoting self-management by advocating for, empowering, and educating a person; and ensuring safe, appropriate, non-duplicative, and effective integrated care.

                       Usage Note: Use when describing these functions: 1. Monitoring a person’s goals, needs, and preferences.   2. Acting as the communication link between two or more participants concerned with a person's health and wellness.  3. Organizing and facilitating care activities and promoting self-management by advocating for, empowering, and educating a person.  4. Ensuring safe, appropriate, non-duplicative, and effective integrated care.

                    The goal is to clearly differentiate this type of coordination of care from HIPAA Operations by specifying that these actions on information are undertaken in the provision of healthcare treatment.

                    For similar uses of this concept, see SAMHSA Confidentiality of Substance Use Disorder Patient Records Supplemental notice of proposed rulemaking, which differentiates concepts of care coordination and case management for the provision of treatment as specifically distinct from activities related to health care delivery management and the operations of organizational entities involved in the delivery of healthcare.

                    
                       Map: Maps to ISO 14265 Classification Terms: "Support of care activities within the provider organisation for an individual subject of care" described as "To inform persons or processes enabling others to provide health care services to the subject of care."  "Subject of Care Uses" described as "To inform the subject of care in support of his or her own interests."

To perform one or more operations on information for provision of health care.

Request for data from payers or providers to determine how to deliver care for a particular patient, group or community.

Request for data from payers or other providers to assess of social risk, establishing coded health concerns/problems, creating patient driven goals, managing interventions, and measuring outcomes.

[Existing concepts do not define a more detailed Payment as defined by HIPAA. Therefore, implicit in using this code is that an implementer must supply an additional, alternate code.

Existing concepts do not define a more detailed Healthcare Operations as defined by HIPAA. Therefore, implicit in using this code is that an implementer must supply an additional, alternate code.

Existing concepts do not define a more detailed Treatment as defined by HIPAA. Therefore, implicit in using this code is that an implementer must supply an additional, alternate code.