Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR
				52.00, the following words mean:
Accreditation
. A written determination
				by the Bureau of Managed Care of compliance with M.G.L. c. 176O,
				211 CMR
				52.00 and
				958 CMR
				3.000:
Health Insurance Consumer
				Protection
.
Actively Practices
. A Health Care
				Professional who regularly treats or manages patients in a clinical
				setting.
Administrative Disenrollment
. A change
				in the status of an Insured whereby the Insured remains with the same Carrier
				but his or her membership may appear under a different identification number.
				Examples of an Administrative Disenrollment are a change in employers, a move
				from an individual plan to a spouse's plan, or any similar change that may be
				recorded by the Carrier as both a disenrollment and an enrollment.
Adverse Determination
. A
				determination, based upon a review of information provided, by a Carrier or its
				designated Utilization Review Organization, to deny, reduce, modify, or
				terminate an admission, continued inpatient stay, or the availability of any
				other Health Care Services, forfailure to meet the requirements for coverage
				based on Medical Necessity, appropriateness of health care setting and level of
				care, or effectiveness, including a determination that a requested or
				recommended Health Care Service or treatment is experimental or
				investigational. An
Adverse Determination
includes any
				denial of access to an out-of-Network Provider at an in-Network benefit level
				where there is an oral or written assertion by an Insured or treating Provider
				that a Carrier's preferred Provider Network does not have Providers who are
				able and available to treat the patient's specific condition and the preferred
				Provider Network is therefore not adequate to deliver the needed benefits at
				the preferred Provider level.
Alternative Payment Contract
. Any
				contract between a Carrier and a Provider or Provider organization that
				utilizes alternative payment methodologies, which are methods of payment that
				are not solely based on fee-for-service reimbursements and that may include,
				but is not limited to, shared savings arrangements, bundled payments, global
				payments, and fee-for-service payments that are settled or reconciled with a
				bundled or global payment.
Ambulatory Review
. Utilization Review
				of Health Care Services performed or provided in an out patient setting,
				including, but not limited to, outpatient or ambulatory surgical, diagnostic
				and therapeutic services provided at any medical, surgical, obstetrical,
				psychiatric and chemical dependency Facility, as well as other locations such
				as laboratories, radiology facilities, Provider offices and patient
				homes.
Asynchronous or Asynchronous
				Telehealth
. An exchange of information regarding a patient that
				does not occur in real time, including but not limited to the secure collection
				and transmission of a patient's medical information, clinical data clinical
				images, laboratory results, or a self-reported medical history.
Behavioral Health Manager
. A company,
				organized under the laws of the Commonwealth of Massachusetts or organized
				under the laws of another state and qualified to do business in the
				Commonwealth, that has entered into a contractual arrangement with a Carrier to
				provide or arrange for the provision of behavioral, substance use disorder and
				mental Health Services to voluntarily enrolled members of the Carrier.
Behavioral Health Services
. Care and
				services for the evaluation, diagnosis, treatment, consultation, prescribing,
				monitoring or management of mental health, developmental, or substance use
				disorders. Such care and services may be provided by any Health Care
				Professional for whom such services are within the scope of licensure for such
				Health Care Professional. Behavioral Health Services shall also include but not
				be limited to Partial Hospital Programs and Intensive Outpatient
				Programs.
Behavioral Health Specialty Care
.
				Behavioral Health Services dedicated to treating particular behavioral health
				conditions. A behavioral health Provider should be listed as providing specific
				Behavioral Health Specialty Care when they regularly provide the care.
Bureau of Managed Care or Bureau
. The
				bureau in the Division of Insurance established by M.G.L. c. 176O, §
				2.
Capitation
. A set payment per patient
				per unit of time made by a Carrier to a licensed Health Care Professional,
				Health Care Provider group, or organization that employs or utilizes services
				of Health Care Professionals to cover a specified set of services and
				administrative costs without regard to the actual number of services
				provided.
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. Unless otherwise noted, the term "Carrier" shall not include any
				entity to the extent it offers a policy, certificate, or contract that is not a
				health benefit plan as defined in M.G.L. c. 176J, § 1.
Case Management
. A coordinated set of
				activities conducted for individual patient management of serious, complicated,
				protracted or other health conditions.
Chronic Disease Management
. Care and
				services for the management of chronic conditions, including
(a) conditions, defined by the federal
			 Centers for Medicare and Medicaid Services that include, but are not limited
			 to, diabetes, chronic obstructive pulmonary disease, asthma, congestive heart
			 failure, hypertension, history of stroke, cancer, and coronary artery
			 disease;
(b) congenital anomalies
			 and hereditary conditions; and
(c)
			 other chronic conditions that last one year or more and require ongoing medical
			 attention or limit activities of daily living or both.
Clean and Complete Credentialing
				Application
. A credentialing application which is appropriately
				signed and dated by the Provider, and which includes all of the applicable
				information requested from the Provider by the Carrier.
Clinical Peer Reviewer
. A physician or
				other Health Care Professional, other than the physician or other Health Care
				Professional who made the initial decision, who holds a nonrestricted license
				from the appropriate professional licensing board in Massachusetts, current
				board certification from a Specialty board approved by the American Board of
				Medical Specialties or of the Advisory Board of Osteopathic Specialists from
				the major areas of clinical services or, for non-physician Health Care
				Professionals, the recognized professional board for their Specialty, who
				Actively Practices in the Same or Similar Specialty as typically manages the
				medical condition, procedure or treatment under review, and whose compensation
				does not directly or indirectly depend upon the quantity, type or cost of the
				services that such person approves ordenies.
Clinical Review Criteria
. The written
				screening procedures, decisions, abstracts, clinical protocols and practice
				guidelines used by a Carrier to determine the Medical Necessity and
				appropriateness of Health Care Services.
Commissioner
. The Commissioner of
				Insurance, appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Complaint
.
(a) any Inquiry made by or on behalf of an
			 Insured to a Carrier or Utilization Review Organization that is not explained
			 or resolved to the Insured's satisfaction within three business Days of the
			 Inquiry;
(b) any matter concerning
			 an Adverse Determination; or
(c) in
			 the case of a Carrier or Utilization Review Organization that does not have an
			 internal Inquiry process, a Complaint means any Inquiry.
Concurrent Review
. Utilization Review
				conducted during an Insured's inpatient hospital stay or course of
				treatment.
Cost Sharing
or
Cost-sharing
. Includes deductibles, coinsurance,
				copayments, or similar charges required of an Insured, but does not include
				premiums, balance-billing amounts for out-of-Network Providers, or spending for
				non-covered Benefits.
Covered Benefits
or
Benefits
. Health Care Services to which an Insured is
				entitled under the terms of the Health Benefit Plan.
Days
. Calendar days, unless otherwise
				specified in
				211 CMR
				52.00; provided, that computation of days specified in
				211 CMR
				52.00 begins with the first day following the
				referenced action, and provided further that if the final day of a period
				specified in
				211 CMR
				52.00 falls on a Saturday, Sunday or state holiday,
				the final day of the period will be deemed to occur on the next working
				day.
Dental Benefit Plan
. A policy,
				contract, certificate or agreement of insurance entered into, offered or issued
				by a Dental Carrier to provide, deliver, arrange for, pay for, or reimburse any
				of the costs solely for Dental Care Services.
Dental Care Professional
. A dentist or
				other dental care practitioner licensed, accredited or certified to perform
				specified Dental Services consistent with the law.
Dental Care Provider
. A Dental Care
				Professional or Facility licensed to provide Dental Care Services.
Dental Care Services
or
Dental Services
. Services for the diagnosis,
				prevention, treatment, cure or relief of a dental condition, illness, injury or
				disease.
Dental Carrier
. An entity that offers
				a policy, certificate or contract that provides coverage solely for Dental Care
				Services and is: an insurer licensed or otherwise authorized to transact 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 dental service corporation organized under
				M.G.L. c. 176E, or 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 or one or more
				subsidiaries or affiliated corporations of the employer, that offers a policy,
				certificate or contract that provides coverage solely for Dental Care
				Services.
Discharge Planning
. The formal process
				for determining, prior to discharge from a Facility, the coordination and
				management of the care that an Insured receives following discharge from a
				Facility.
Division
. The Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Emergency Medical Condition
. A medical
				condition, whether physical, behavioral, related to substance use disorder, or
				mental, manifesting itself by symptoms of sufficient severity, including severe
				pain, that the absence of prompt medical attention could reasonably be expected
				by a prudent layperson who possesses an average knowledge of health and
				medicine, to result in placing the health of an Insured or another person in
				serious jeopardy, serious impairment to body function, or serious dysfunction
				of any body organ or part, or, with respect to a pregnant woman, as further
				defined in § 1867(e)(l)(B) of the Social Security Act,
				42 U.S.C.§
										1395dd(e)(1)(B).
Evidence of Coverage
. Any certificate,
				contract or agreement of health insurance including riders, amendments,
				endorsements and any other supplementary inserts or a summary plan description
				pursuant to § 104(b)(1) of the Employee Retirement Income Security Act of
				1974, 29 U.S.C. §
										1024(b), issued to an
				Insured specifying the Benefits to which the Insured is entitled. For workers'
				compensation preferred Provider arrangements, the Evidence of Coverage will be
				considered to be the information annually distributed pursuant to
				211
				CMR 51.04(3)(i)1. through
				3.
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.
Finding of Neglect
. A written
				determination by the Commissioner that a Carrier has failed to make and file
				the materials required by M.G.L. c. 176O or
				211 CMR
				52.00 in the form and within the time required.
Grievance
. Any oral or written
				Complaint submitted to the Carrier that has been initiated by an Insured, or on
				behalf of an Insured with the consent of the Insured, concerning any aspect or
				action of the Carrier relative to the Insured including, but not limited to,
				review of Adverse Determinations regarding scope of coverage, denial of
				services, rescission of coverage, quality of care and administrative
				operations, in accordance with the requirements of M.G.L. c. 176O and
				958 CMR
				3.000:
Health Insurance Consumer
				Protection
.
Health Benefit Plan
. A policy,
				contract, certificate or agreement of insurance entered into, offered or issued
				by a Carrier to provide, deliver, arrange for, pay for, or reimburse any of the
				costs of Health Care Services. Unless otherwise noted,
Health
				Benefit Plan
shall not include any policy, certificate, or
				contract that is not a health benefit plan as defined in M.G.L. c. 176J, §
				1.
Health Care Professional
. A physician
				or other health care practitioner licensed, accredited or certified to perform
				specified Health Services consistent with the law.
Health Care Provider
or
Provider
. A Health Care Professional or
				Facility.
Health Care Services
or
Health Services
. Services for the evaluation,
				consultation, prescribing, diagnosis, prevention, treatment, management, cure
				or relief of a physical, behavioral, substance use disorder or mental health
				condition, illness, injury or disease.
HMO
. A health maintenance organization
				licensed pursuant to M.G.L. c. 176G.
Incentive Plan
. Any compensation
				arrangement between a Carrier and Health Care Professional or Licensed Health
				Care Provider Group or organization that employs or utilizes services of one or
				more licensed Health Care Professionals that may directly or indirectly have
				the effect of reducing or limiting specific services furnished to Insureds of
				the organization.
Incentive Plan
shall not mean
				contracts that involve general payments such as Capitation payments or shared
				risk agreements that are made with respect to Health Care Professionals or
				Providers, or Health Care Professional groups or Provider groups which are made
				with respect to groups of Insureds if such contracts, which impose risk on such
				Health Care Professionals or Providers or Health Care Professional groups or
				Provider groups for the cost of medical care, services and equipment provided
				or authorized by another Health Care Professional or Provider or by another
				Health Care Professional group or Provider group, comply with
				211 CMR
				52.00.
Inquiry
. Any communication by or on
				behalf of an Insured to the Carrier or Utilization Review Organization that has
				not been the subject of an Adverse Determination and that requests redress of
				an action, omission or policy of the Carrier.
Insured
. An enrollee, covered person,
				Insured, member, policy holder or subscriber of a Carrier, including a Dental
				or Vision Carrier, including an individual whose eligibility as an Insured of a
				Carrier is in dispute or under review, or any other individual whose care may
				be subject to review by a Utilization Review program or entity as described
				under the provisions of M.G.L. c. 176O,
				211 CMR
				52.00 and
				958 CMR
				3.000:
Health Insurance Consumer
				Protection
.
Internet Website
. Includes, but shall
				not be limited to, an internet website, an intranet website, a web portal, or
				electronic mail.
JCAHO
. The Joint Commission on
				Accreditation of Health Care Organizations.
Licensed Health Care Provider Group
. A
				partnership, association, corporation, individual practice association, or
				other group that distributes income from the practice among members. An
				individual practice association is a Licensed Health Care Provider Group only
				if it is composed of individual Health Care Professionals and has no
				subcontracts with Licensed Health Care Provider Groups.
Limited Health Services
.
				Pharmaceutical services, and such other services as may be determined by the
				Commissioner to be Limited Health Services.
Limited Health
				Services
shall not include hospital, medical, surgical or
				emergency services, except as such services are provided in conjunction with
				the Limited Health Services set forth in the preceding sentence.
Limited Network Plan
. A Limited
				Network plan as defined in
				211 CMR
				152.00:
Health Benefit Plans Using Limited,
				Regional or Tiered Provider Networks
.
Managed Care Organization
or
MCO
. A Carrier subject to M.G.L. c. 176O.
Material Change
. A modification to any
				of a Carrier's, including a Dental or Vision Carrier's, procedures or documents
				required by
				211 CMR
				52.00 that substantially affects the rights or
				responsibilities of:
(a) an
			 Insured;
(b) a Carrier, including a
			 Dental or Vision Carrier; and/or
(c) a Health, Dental, or Vision Care
			 Provider.
Medical Necessity
or
Medically Necessary
. Health Care Services that are
				consistent with generally accepted principles of professional medical practice
				as determined by whether:
(a) the
			 service is the most appropriate available supply or level of service for the
			 Insured in question considering potential benefits and harms to the
			 individual;
(b) is known to be
			 effective, based on scientific evidence, professional standards and expert
			 opinion, in improving health outcomes; or
(c) for services and interventions not in
			 widespread use, is based on scientific evidence.
National Accreditation Organization
.
				JCAHO, NCQA, URAC or any other national Accreditation entity approved by the
				Division that accredits Carriers that are subject to the provisions of M.G.L.
				c. 176O and
				211 CMR
				52.00.
NCQA
. The National Committee for
				Quality Assurance.
NCQA Standards
. The Standards and
				Guidelines for the Accreditation of Health Plans published annually by the
				NCQA.
Network
or
Provider
				Network
. A group of health, Dental or Vision Care Providers who
				contract with a Carrier, including a Dental or Vision Carrier, or affiliate to
				provide health, Dental or Vision Care Services to Insureds covered by any or
				all of the Carrier's, including a Dental or Vision Carrier's or affiliate's,
				plans, policies, contracts or other arrangements. Network shall not mean those
				Participating Providers who provide services to subscribers of a nonprofit
				hospital service corporation organized under M.G.L. c. 176A, or a nonprofit
				medical service corporation organized under M.G.L. c. 176B.
Nongatekeeper Preferred Provider Plan
.
				An insured preferred Provider plan approved for offer under M.G.L. c. 176I
				which offers preferred Benefits when a covered person receives care from
				preferred Network Providers but does not require the Insured to designate a
				Primary Care Provider to coordinate the delivery of care or receive referrals
				from the Carrier or any Network Provider as a condition of receiving Benefits
				at the preferred benefit level.
Nurse Practitioner
. A registered nurse
				who holds authorization in advanced nursing practice as a nurse practitioner
				under M.G.L. c. 112, § 80B.
Office of Patient Protection
. The
				office within the Health Policy Commission established by M.G.L. c. 6D, §
				16, responsible for the administration and enforcement of M.G.L. c. 176O,
				§§ 13, 14, 15 and 16.
Participating Provider
. A Provider
				who, under a contract with the Carrier, including a Dental or Vision Carrier,
				or with its contractor or subcontractor, has agreed to provide health, Dental
				or Vision Care Services to Insureds with an expectation of receiving payment,
				other than coinsurance, copayments or deductibles, directly or indirectly from
				the Carrier, including a Dental or Vision Carrier.
Physician Assistant
. A person who is a
				graduate of an approved program for the training of physician assistants who is
				supervised by a registered physician in accordance with M.G.L. c. 112, §
				9C through 9H and who has passed the Physician Assistant National Certifying
				Exam or its equivalent.
Preventive Health Services
. Any
				periodic, routine, screening or other services designed for the prevention and
				early detection of illness that a Carrier is required to provide pursuant to
				Massachusetts or federal law.
Primary Care Provider
. A Health Care
				Professional qualified to provide general medical care for common health care
				problems, who supervises, coordinates, prescribes, or otherwise provides or
				proposes Health Care Services; initiates referrals for Specialty Care; and
				maintains continuity of care within the scope of his or her practice. A Primary
				Care Provider may include but not be limited to medical doctors and Nurse
				Practitioners and Physician Assistants who concentrate in primary care,
				pediatric primary care, and/or gynecological and reproductive health.
Primary Care Services
. Services
				delivered by a Primary Care Provider.
Prospective Review
. Utilization Review
				conducted prior to an admission or a course of treatment.
Prospective Review
shall include any pre-authorization
				and pre-certification requirements of a Carrier or Utilization Review
				Organization.
Regional Network Plan
. A Regional
				Network Plan as defined in
				211 CMR
				152.00:
Health Benefit Plans Using Limited,
				Regional or Tiered Provider Networks.
Religious Non-medical Provider
. A
				Provider who provides no medical care but who provides only religious
				non-medical treatment or religious non-medical nursing care.
Retrospective Review
. Utilization
				Review of Medical Necessity that is conducted after services have been provided
				to a patient.
Retrospective Review
shall not include
				the review of a claim that is limited to an evaluation of reimbursement levels,
				veracity of documentation, accuracy of coding or adjudication for
				payment.
Same
or
Similar
				Specialty
. The Health Care Professional has similar credentials
				and licensure as those who typically provide the treatment in question and has
				experience treating the same condition that is the subject of the Grievance.
				Such experience shall extend to the treatment of children in a Grievance
				involving a child where the age of the patient is relevant to the determination
				of whether a requested service or supply is Medically Necessary.
Second Opinion
. An opportunity or
				requirement to obtain a clinical evaluation by a Health Care Professional other
				than the Health Care Professional who made the original recommendation for a
				proposed Health Service, to assess the clinical necessity and appropriateness
				of the initial proposed Health Service.
Service Area
. The geographical area as
				approved by the Commissioner within which the Carrier, including a Dental or
				Vision Carrier, has developed a Network of Providers to afford adequate access
				to members for covered Health, Dental or Vision Services.
Site of Service Plan
. An insured
				Health Benefit Plan where access to certain specified Network Providers or
				access to care in certain specified settings may only be available when the
				Carrier determines that it is medically necessary to receive covered care from
				these certain Providers or the certain settings. The Utilization Review
				processes and Medical Necessity criteria used are required to meet the relevant
				requirements of
				211 CMR
				52.00 and any requirements as determined by the
				Commissioner. Whenever a request for services provided by certain specified
				Network Providers for care at certain specified locations is denied, Carriers
				with Site of Service Plans are to follow all required protocols for Adverse
				Determination notices and appeals as required under
				211 CMR
				52.00.
Specialty or Specialty Care
. Health
				Care services dedicated to a specific branch of medicine or all Health Care
				services not considered primary care. Patients can be referred to a specialist
				by a Primary Care Provider for disease-specific care that requires expert
				support.
Telehealth
. The use of synchronous or
				asynchronous audio, video, electronic media or other telecommunications
				technology including, but not limited to:
(i) interactive audio-video
			 technology;
(ii) remote patient
			 monitoring devices;
(iii)
			 audio-only telephone; and
(iv)
			 online adaptive interviews, for the purpose of evaluating, diagnosing,
			 consulting, prescribing, treating, managing, or monitoring of a patient's
			 physical health, oral health, mental health or substance use disorder
			 condition.
Terminally Ill
or
Terminal
				Illness
. An illness that is likely, within a reasonable degree of
				medical certainty, to cause one's death within six months, or as otherwise
				defined in section 1861(dd)(3)(A) of the Social Security Act,
				42 U.S.C. §
											1395x(dd)(3)(A).
Tiered Network Plan
. A Tiered Network
				Plan as described in
				211 CMR
				152.00:
Health Benefit Plans Using Limited,
				Regional or Tiered Provider Networks
.
URAC
. The American Accreditation
				Health Care Commission/URAC, formerly known as the Utilization Review
				Accreditation Commission.
Utilization Review
. Set of formal
				techniques designed to monitor the use of, or evaluate the clinical necessity,
				appropriateness, efficacy, or efficiency of, Health Care Services, procedures
				or settings. Such techniques may include, but are not limited to, Ambulatory
				Review, Prospective Review, Second Opinion, certification, Concurrent Review,
				Case Management, Discharge Planning or Retrospective Review.
Utilization Review Organization
. An
				entity that conducts Utilization Review under contract with or on behalf of a
				Carrier, but does not include a Carrier performing Utilization Review for its
				own Health Benefit Plans. A Behavioral Health Manager is considered a
				Utilization Review Organization.
Vision Benefit Plan
. A policy,
				contract, certificate or agreement of insurance entered into, offered or issued
				by a Carrier to provide, deliver, arrange for, pay for, or reimburse any of the
				costs solely for Vision Care Services.
Vision Care Professional
. An
				ophthalmologist, optometrist or other practitioner licensed, accredited or
				certified to perform specified Vision Services consistent with the law.
Vision Care Provider
. A Vision Care
				Professional; or a Facility licensed to perform and provide Vision Care
				Services.
Vision Care Services
or
Vision Services
. Services for the diagnosis,
				prevention, treatment, cure or relief of a vision condition, illness, injury or
				disease.
Vision Carrier
. An entity that offers
				a policy, certificate or contract that provides coverage solely for Vision Care
				Services and is: an insurer licensed or otherwise authorized to transact
				accident or health insurance under M.G.L. c. 175; an optometric service
				corporation organized under M.G.L. c. 176F, or 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, that offers a policy, certificate or contract that provides coverage
				solely for Vision Care Services.
Visit
. A scheduled, urgent, or
				emergency encounter between a covered patient and a Health Care Professional,
				whether conducted within the Health Care Professional's office, another
				physical location or conducted via synchronous or Asynchronous Telehealth, to
				evaluate, diagnose, consult, treat, conduct clinical trials, prescribe, manage
				or monitor a covered medical, oral health or behavioral health condition.
				Within a Visit, the Health Care Professional will review patient history,
				examine the patient's condition, and exercise medical judgment in treating a
				patient. In the case of Telehealth Visits, a Health Care Professional must
				receive consent from a patient that the encounter will constitute a Visit and
				may be subject to Health Benefit Plan Cost-sharing if the Health Care
				Professional ever seeks reimbursement for the Telehealth encounter from either
				the patient or the patient's Carrier.