Health care operations Policy Term Definition


Any one of the following activities to the extent the activities are related to providing health care:

  1. Conducting quality assessment and improvement activities including outcomes, evaluation and development of clinical guidelines, provided that the obtaining of generalizable knowledge is not the primary purpose of any studies resulting from such activities; patient safety activities (as defined in 42 CFR 3.20); population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting of health care providers and patients with information about treatment alternatives, and related functions that do not involve treatment
  2. Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance, conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals, accreditation, certification, licensing, or credentialing activities
  3. Underwriting, enrollment, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relating to claims for health care
  4. Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs
  5. Business planning and development, such as conducting cost management and planning related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or covered policies
  6. Business management and general administrative activities:
  • Management activities related to HIPAA compliance
  • Customer Service
  • Resolution of internal grievances
  • Sale, transfer, merger, or consolidation of covered entities, creating de-identified health information or limited data set, and fundraising for the benefit of UTMB