Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 23.00 - PAYER REPORTING OF TOTAL MEDICAL EXPENSES AND RELATIVE PRICES › Section 23.02 - Definitions

Current through Register 1525, July 5, 2024
The following terms as used in 114.5 CMR 23.00 have the
				following meanings, except where the context clearly indicates
				otherwise:
Allowed Claims
. Paid medical claims
				plus related Member liabilities, including, but not limited to, co-pays,
				co-insurance, and deductibles.
Ancillary Services
. Non-routine
				services for which charges are customarily made in addition to routine charges,
				that include, but are not limited to, laboratory, diagnostic and therapeutic
				radiology, surgical services, and physical, occupational, or speech-language
				therapy.
Calendar Year
. The period beginning
				January 1st and ending December
				31st.
Commissioner
. The Commissioner of the
				Division of Health Care Finance and Policy.
Data Specification Manual
. The Data
				Specification Manual contains data submission requirements, including, but not
				limited to, required fields, file layouts, file components, edit
				specifications, and other technical specifications.
Division
. The Division of Health Care
				Finance and Policy established under M.G.L. c. 118G.
Health Care Payer (Payer)
. A Private
				or Public Health Care Payer that contracts or offers to provide, deliver,
				arrange for, pay for, or reimburse any of the costs of Health Care Services. A
				Health Care Payer includes an insurance carrier, a health maintenance
				organization, a nonprofit hospital services corporation, a medical service
				corporation, a Third Party Administrator, and a self-insured health
				plan.
Health Care Services
. Supplies, care
				and services of medical, surgical, optometric, dental, podiatric, chiropractic,
				psychiatric, 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 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 by a health maintenance organization.
Health Status Adjusted Total Medical Expenses
				(TME)
. The total cost of care for the patient population
				associated with a provider group based on allowed claims for all categories of
				medical expenses and all non-claims related payments to providers, adjusted by
				health status, and expressed on a Per Member Per Month basis, as calculated
				under 114.5 CMR 23.04.
Hospital
. A hospital licensed by the
				Department of Public Health in accordance with the provisions of M.G.L. c.
				111.
Member
. A person who holds an
				individual contract or a certificate under a group arrangement contracted with
				a Health Care Payer.
Member Months
. The number of Members
				participating in a plan over a specified period of time expressed in months of
				membership.
Non-claims Related Payments
. Payments
				made to providers not directly related to a medical claim including, but not
				limited to, pay for performance, care management payments, infrastructure
				payments, grants, surplus payments, lump sum settlements, capitation
				settlements, signing bonuses, governmental payer shortfall payments,
				infrastructure, medical director, and health information technology
				payments.
Payments Subject to Surcharge
.
				Payments subject to the surcharge established by M.G.L. c. 118G, § 38,
				including payments defined under 114.6 CMR 14.05(1)(b) and excluding payments
				defined under 114.6 CMR 14.05(1)(c).
Pediatric Physician Practice
. A
				physician group practice in which at least 75% of its patients are children up
				to the age of 18.
Per Member Per Month (PMPM)
. An
				adjustment made by dividing an annual amount by Member Months.
Physician Group
. A medical practice
				comprised of two or more physicians organized to provide patient care services
				(regardless of its legal form or ownership).
Physician Local Practice Group
. A
				geographically organized subgroup of a Physician Group that provides primary
				care.
Private Health Care Payer
. A carrier
				authorized to transact accident and health insurance under M.G.L. c. 175, a
				nonprofit hospital service corporation licensed under M.G.L. c. 176A, a
				nonprofit medical service corporation licensed under M.G.L. c. 176B, a dental
				service corporation organized under M.G.L. c. 176E, an optometric service
				corporation organized under M.G.L. c. 176F, a self-insured plan, a third party
				administrator, or a health maintenance organization licensed under M.G.L. c.
				176G. Private Health Care Payers include any carrier or Third Party
				Administrator that contracts with the office of Medicaid, the Commonwealth
				Health Insurance Connector, or the Group Insurance Commission to pay for or
				arrange for the purchase of health care services on behalf of individuals
				enrolled in health coverage programs under Titles XVIII, XIX, or XXI, under the
				Commonwealth Care Health Insurance program, Medicaid managed care
				organizations, or under the Group Insurance Commission.
Provider
. 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.
Public Health Care Payer
. The Medicaid
				program established in M.G.L. c. 118E and any city or town with a population of
				more than 60,000 that has adopted M.G.L. c. 32B.
Relative Prices
. The contractually
				negotiated amounts paid to Massachusetts providers by each Private and Public
				Payer for health care services, including Non-Claims Related Payments and
				expressed in the aggregate relative to the payer's network wide average amount
				paid to providers, as calculated under 114.5 CMR 23.05.
Routine Services
. The regular room and
				board services, daily nursing care, minor medical and surgical supplies, and
				the use of equipment and facilities.
Surcharge
. The surcharge on payments
				made to Hospitals and Ambulatory Surgical Centers established by M.G.L. c.
				118G, § 38 and 114.6 CMR 14.00.
Surcharge Payer
. An individual or
				entity that:
(a) makes payments for the purchase of health care Hospital
				Services and Ambulatory Surgical Center Services; and
(b) meets the criteria set forth in 114.6 CMR
				14.05(1)(a).
Third Party Administrator
. An entity
				who, on behalf of a health insurer or purchaser of health benefits, receives or
				collects charges, contributions, or premiums for, or adjusts or settles claims
				on or for residents of the Commonwealth. Third Party Administrators shall also
				include pharmacy benefit managers and any other entity with claims data,
				eligibility data, provider files, and other information relating to health care
				provided to residents of the Commonwealth and health care provided by health
				care providers in the Commonwealth except that Third Party Administrators shall
				not include an entity that administers only claims data, eligibility data,
				provider files, and other information for its own employees and
				dependents.
Total Medical Claims
. Total allowed
				claims for all categories of medical expenses including, but not limited to,
				hospital inpatient, hospital outpatient, sub-acute such as skilled nursing and
				rehabilitation, professional, pharmacy, mental health and behavioral health and
				substance abuse, home health, durable medical equipment, laboratory, diagnostic
				imaging and alternative care such as chiropractic and acupuncture claims,
				incurred under all fully insured and self-insured plans.