In health care, an entity that assumes the risk of paying for medical treatments. This can be an uninsured patient, a self­insured employer, or a health care plan or HMO. 


  1. The activities undertaken by: 

    1. A health plan to obtain premiums or to determine or fulfill its responsibility for coverage and provision of benefits under the health plan; or 

    2. A covered health care provider or health plan to obtain or provide reimbursement for the provision of health care; and

  2. The activities in paragraph (1) of this definition relate to the individual to whom health care is provided and include, but are not limited to: 

    1. Determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), and adjudication or subrogation of health benefit claims; 

    2. Risk adjusting amounts due based on enrollee health status and demographic characteristics; 

    3. Billing, claims management, collection activities, obtaining payment under a contract for reinsurance (including stop-loss insurance and excess of loss insurance), and related health care data processing; 

    4. Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges; 

    5. Utilization review activities, including precertification and preauthorization of services, concurrent and retrospective review of services; and 

    6. Disclosure to consumer reporting agencies of any of the following protected health information relating to collection of premiums or reimbursement: 

      1. Name and address; 

      2. Date of birth; 

      3. Social security number; 

      4. Payment history; 

      5. Account number; and 

      6. Name and address of the health care provider and/or health plan.
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