Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 320.00 - Rates for Clinical Laboratory Services › Section 320.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				101
				CMR 320.00, terms have the meanings ascribed in 101
				CMR 320.02.
Allowable Fee
. The amount of
				reimbursement that is paid by all governmental units for a laboratory service,
				as set forth in
				101 CMR
				320.04 and
				101 CMR
				320.05.
Bulk Purchase
. A single purchase of a
				laboratory service (one or more tests) to be uniformly and concurrently
				performed on a minimum of 40 specimens of the same type. A single purchase of
				various, non-uniform laboratory services, such as by a physician, is not
				considered a bulk purchase, regardless of the number of specimens presented by
				such a purchaser to the laboratory.
Charge
. The price of a laboratory
				service as determined by the clinical laboratory performing the service.
Clinical Laboratory
. A laboratory
				where microbiological, chemical, hematological, biophysical, cytological,
				immuno-hematological, or pathological examinations are performed on materials
				derived from the human body to provide information for the diagnosis,
				prevention, or treatment of a disease or assessment of a medical
				condition.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
Eligible Provider of Laboratory
				Services
. A person licensed by an appropriate Board of
				Registration to perform clinical laboratory services, such registration being
				in accordance with the provisions of M.G.L. c. 112; or an independent
				laboratory. Such persons and laboratories must meet all conditions of
				participation that have been or may be adopted by a governmental unit that
				purchases laboratory services. For purposes of
				101
				CMR 320.00, eligible providers of laboratory services
				do not include hospital laboratories.
EOHHS
. The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Fee Schedule
. (Description of Service
				and HCPCS/CPT Procedure Code). The Healthcare Common Procedure Coding System
				(HCPCS), which is based upon the American Medical Association (AMA) Current
				Procedural Terminology (CPT), is the basis by which all procedures are
				performed. The CPT handbook is updated by the AMA annually. All non-physician
				codes and terminology is defined by the Centers for Medicare & Medicaid
				Services (CMS) and set forth in the HCPCS file.
Governmental Unit
. The Commonwealth,
				any department, division, agency, board, or commission of the Commonwealth and
				any political subdivision of the Commonwealth.
Independent Clinical Laboratory
. A
				clinical laboratory that is operated independently from a hospital or from an
				attending or consulting physician's office. If the laboratory is operated or
				directed by one or more licensed physicians, it must offer its services to
				other physicians to qualify as an independent clinical laboratory. In cases
				where two or more distinct, physically separated laboratory facilities operate
				under the same name and the same director, each facility that performs clinical
				laboratory services is treated as a separate independent clinical
				laboratory.
Profile (or Panel) Tests
. Any group of
				tests, whether performed manually, automated, or semi-automated, that is
				ordered for a specific patient on a specified day, and has at least one of the
				following characteristics.
(a) The group of tests is designated as a profile or panel by
				the clinical laboratory performing the tests.
(b) The group of tests is performed by the clinical laboratory
				and the customary charge is less than the sum of that clinical laboratory's
				usual and customary charges for the individual tests in that group.
Publicly Aided Individual
. A person
				who receives medical care and services for which a governmental unit is liable,
				in whole or in part, under a statutory program of public assistance.
Rate
. The lesser of the charge or the
				allowable fee, as defined in 101 CMR 320.02.
Usual and Customary Charge
. The lowest
				fee charged by an independent clinical laboratory for any laboratory service
				(including individual and profile tests) specified by
				101
				CMR 320.00 or by such independent clinical laboratory,
				which fee is in effect at the time such laboratory service is performed, other
				than a fee offered for a bulk purchase, as defined in 101 CMR 320.02.