Payment The activities undertaken by: A health plan to obtain premiums or to determine or fulfill its responsibility for coverage and provision of benefits under the health plan; or A covered health care provider or health plan to obtain or provide reimbursement for the provision of health care; and 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: Determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), and adjudication or subrogation of health benefit claims; Risk adjusting amounts due based on enrollee health status and demographic characteristics; 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; Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges; Utilization review activities, including precertification and preauthorization of services, concurrent and retrospective review of services; and Disclosure to consumer reporting agencies of any of the following protected health information relating to collection of premiums or reimbursement: Name and address; Date of birth; Social security number; Payment history; Account number; and Name and address of the health care provider and/or health plan. Legislation Files Containing This Term: legislation/12CFR-205.2.html legislation/45CFR-160.103.html legislation/45CFR-162.1601.html legislation/45CFR-162.1602.html legislation/45CFR-162.1702.html legislation/45CFR-162.1801.html legislation/45CFR-162.920.html legislation/45CFR-164.501.html legislation/45CFR-164.508.html Web Pages Containing This Term: factSheet04022002.html