Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 11.00 - Registered Provider Organizations Reporting Requirements › Section 11.02 - Definitions

Current through Register 1525, July 5, 2024
All defined terms in 957 CMR 11.00 are capitalized. As used in
				957 CMR 11.00 and the
Data Submission Manual
, unless the
				context requires otherwise, the following terms shall have the following
				meanings:
Acute Hospital
. The teaching hospital
				of the University of Massachusetts Medical School and any hospital licensed
				under M.G.L. c. 111, § 51 and which contains a majority of
				medical-surgical, pediatric, obstetric, and maternity beds, as defined by the
				Department of Public Health.
Advanced Care Settings
. Sites at which
				more complex care can be provided for one or more clinical services.
Audited Financial Statements
. A
				complete set of financial statements of an Entity, including the notes to the
				financial statements, which are subject to an independent audit in accordance
				with
Generally Accepted Auditing Standards (GAAS)
. The
				independent auditor issues an opinion as to whether or not the accompanying
				financial statements are presented fairly in accordance with
Generally
				Accepted Accounting Principles (GAAP)
.
Behavioral Health Services
. Supplies,
				care, and services for the diagnosis, treatment, or management of patients with
				mental health or substance use disorders.
Carrier. An insurer licensed or otherwise authorized to
				transact accident or health insurance under M.G.L. c. 175; a nonprofit hospital
				service corporation organized under M.G.L. c. 176A; a nonprofit medical service
				corporation organized under M.G.L. c. 176B; a health maintenance organization
				organized under M.G.L. c. 176G; and an organization entering into a preferred
				provider arrangement under M.G.L. c. 176I, but not including an employer
				purchasing coverage or acting on behalf of its employees or the employees of
				one or more subsidiaries or affiliated corporations of the employer; provided
				that, unless otherwise noted,
Carrier
shall not
				include any Entity to the extent it offers a policy, certificate or contract
				that provides coverage solely for dental care services or vision care
				services.
Center. The Center for Health Information and Analysis
				established in M.G.L. c. 12C.
Clinical Affiliation
. Any relationship
				between a Provider or Provider Organization and another Entity for the purpose
				of increasing the level of collaboration in the provision of Health Care
				Services, including, but not limited to, sharing of physician resources in
				hospital or other ambulatory settings, co-branding, expedited transfers to
				Advanced Care Settings, provision of inpatient consultation coverage or call
				coverage, enhanced electronic access and communication, co-located services,
				provision of capital for service site development, Joint Training Programs,
				video technology to increase access to expert resources and sharing of
				hospitalists or intensivists.
Commission
. The Health Policy
				Commission established in M.G.L. c. 6D.
Community Advisory Board
. Committees,
				boards, or other oversight and governance bodies engaging the community of a
				Provider Organization, including, but not limited to patient and family
				advisory councils, as defined in
				105
				CMR 130.1801:
Policies and Procedures
				for Patient and Family Advisory Council
, or community benefits
				advisory boards.
Consolidating Schedule
. A document
				that accompanies the consolidated Audited Financial Statements, which includes
				detailed financial statements of subsidiary hospital(s) and the other
				organizations that comprise the consolidated entity.
Contracting Affiliation
. Any
				relationship between a Provider Organization and another Provider or Provider
				Organization for the purposes of negotiating, representing, or otherwise acting
				to establish contracts for the payment of Health Care Services, including for
				payment rates, incentives, and operating terms, with a Payer or Third-party
				Administrator.
Corporate Affiliation
. Any
				relationship between two Entities that reflects, directly or indirectly, a
				partial or complete controlling interest or partial or complete common
				control.
Data Submission
				Manual
. A manual published by the MA-RPO Program as an
				administrative bulletin, containing specifications, submission guidelines, and
				timelines for Registration and data collection.
Division. The Massachusetts Division of Insurance established
				in M.G.L. c. 26, § 1.
Entity
. A corporation, sole
				proprietorship, partnership, limited liability company, trust, foundation, or
				any other organization formed for the purpose of carrying on a commercial or
				charitable enterprise.
Facility
. A licensed institution
				providing Health Care Services, or a health care setting, including, but not
				limited to, hospitals and other licensed inpatient centers, ambulatory surgical
				or treatment centers, skilled nursing centers, residential treatment centers,
				diagnostic, laboratory and imaging centers, and rehabilitation and other
				therapeutic health settings.
Fiscal Year
. The 12-month period
				during which a Provider Organization keeps its accounts and which is identified
				by the calendar year in which it ends.
Full-time Equivalent
. The ratio of the
				total payroll hours for employees to the standard number of annual full-time
				payroll hours, and the equivalent for contracted individuals.
Funds Flow
. The apportionment of
				Provider or Provider Organization funds, including payments from Payers and
				Third-party Administrators, across affiliated Entities, which shall include
				apportionment across hospitals and physicians, across physician groups, across
				primary care physicians and specialists, and across employed versus affiliated
				physicians.
Governmental Unit
. The Commonwealth,
				any board, commission, department, division, or agency of the Commonwealth, and
				any political subdivision of the Commonwealth.
Health Care Professional
. A physician
				or other health care practitioner licensed, accredited, or certified to perform
				specified Health Care Services consistent with law.
Health Care Provider or Provider
. A
				provider of Health Care Services or any other person or organization that
				furnishes, bills or is paid for Health Care Services delivery in the normal
				course of business or any person, corporation, partnership, governmental unit,
				state institution or any other entity qualified under the laws of the
				Commonwealth to perform or provide Health Care Services.
Health Care Services
. Supplies, care
				and services of medical, Behavioral Health, surgical, optometric, dental,
				podiatric, chiropractic, therapeutic, diagnostic, preventative, rehabilitative,
				supportive or geriatric nature including, but not limited to, inpatient and
				outpatient acute hospital care and services; services provided by a community
				health center, home health care provider, and hospice care provider, or by a
				sanatorium, as included in the definition of "hospital" in Title XVIII of the
				federal Social Security Act, and treatment and care compatible with such
				services, or provided by a health maintenance organization.
Initial Registration
. The first time a
				Provider Organization submits an application for Registration, which
				application may include one or more parts.
Joint Training Programs
. A training
				program, including but not limited to student education and graduate medical
				education, jointly sponsored by one or more Providers or Provider
				Organizations.
Local Practice Group
. A group of
				Health Care Professionals that functions as a subgroup of a Provider
				Organization (
i.e.
, groups broken out from the larger Provider
				Organization for purposes of data reporting and market comparisons).
Major Service Category
. A set of
				service categories as specified in the
Data Submission Manual
,
				including:
(a) Acute Hospital inpatient services, by major diagnostic
				category;
(b) outpatient and ambulatory services, by categories as
				defined by the Centers for Medicare and Medicaid Services, or as specified in
				the
Data Submission Manual
, not to exceed 15, including a
				residual category for "all other" outpatient and ambulatory services that do
				not fall within a defined category;
(c) Behavioral Health Services;
(d) professional services, by categories as defined by the
				Centers for Medicare and Medicaid Services, or as specified in the
Data
				Submission Manual
; and
(e) sub-acute services, by major service line or clinical
				offering, as specified in the
Data Submission Manual
.
Massachusetts Registration of Provider
				Organizations Program
or
MA-RPO Program
.
				The Commonwealth program, jointly administered by the Commission and the
				Center, pursuant to M.G.L. c. 6D, § 11 and § 12 and M.G.L. c.
				12C.
Patient Panel
. The total number of
				individual patients seen over the course of the most recent complete 36-month
				period.
Payer. Any entity, other than an individual, that pays
				providers for the provision of health care services; provided, that
Payer
shall include both governmental and private
				entities; provided further, that
Payer
shall not
				include excluded ERISA plans.
Practice Site
. Any site at which
				members of a Local Practice Group provide care.
Provider Organization or Health System or
				System
. Any corporation, partnership, business trust, association
				or organized group of persons, which is in the business of health care delivery
				or management, whether incorporated or not, that represents one or more Health
				Care Providers in contracting with Carriers or Third-party Administrators for
				the payment of Health Care Services; provided that the definition shall
				include, but not be limited to, physician organizations, physician-hospital
				organizations, independent practice associations, Provider networks,
				accountable care organizations, and any other organization that contracts with
				Carriers or Third-party Administrators for payment for Health Care
				Services.
Registration
. The process of becoming
				a Registered Provider Organization as established by the Commission pursuant to
				M.G.L. c. 6D, § 11, including Initial Registration and Registration
				Renewal.
Registration Renewal
. The process for
				a Registered Provider Organization to renew its Registration every 24
				months.
Registered Provider Organization
				(RPO)
. A Provider Organization, which includes a Risk-bearing
				Provider Organization, that meets the criteria for Registration pursuant to
				958 CMR 6.00:
Registration of Provider Organizations
and registers with the
				Commission.
Risk-bearing Provider Organization
				(RBPO)
. An Entity subject to the requirements of the Division
				pursuant to M.G.L. c. 176T.
Risk Certificate
. A certificate of
				solvency issued by the Division that demonstrates that a Risk-bearing Provider
				Organization has satisfied the certification requirements of M.G.L. c. 176T and
				211 CMR 155.00:
Risk-bearing Provider Organizations
.
Third-party Administrator
. An Entity
				that administers payments for Health Care Services on behalf of a client in
				exchange for an administrative fee.