Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.101 - Definitions

Current through Register 1525, July 5, 2024
A number of common words and expressions are specifically
				defined here. Whenever one of them is used in
				130 CMR 450.000, or in a
				provider contract, it will have the meaning given in the definition, unless the
				context clearly requires a different meaning. When appropriate, definitions may
				include a reference to federal and state laws and regulations.
Accountable Care Organization (ACO)
-
				an entity that enters into a population-based payment model contract with EOHHS
				as an accountable care organization, wherein the entity is held financially
				accountable for the cost and quality of care for an attributed or enrolled
				member population. ACOs include Accountable Care Partnership Plans, Primary
				Care ACOs, and MCO-administered ACOs.
Accountable Care Partnership Plan
- a
				type of ACO with which the MassHealth agency contracts under its ACO program to
				provide, arrange for, and coordinate care and certain other medical services to
				members on a capitated basis and is approved by the Massachusetts Division of
				Insurance as a health-maintenance organization (HMO) and is organized primarily
				for the purpose of providing health care services.
Administrative Action
- a measure
				taken by the MassHealth agency to correct or prevent the recurrence of an
				unacceptable course of action by a provider including, but not limited to, the
				imposition of an administrative fine or other sanction.
Applicant
- a person who completes and
				submits an application for MassHealth, and is awaiting the decision of
				eligibility.
Audit
- an examination by the
				MassHealth agency of a provider's practices by means of an on-site visit, a
				review of the MassHealth agency's claim and payment records, a review of a
				provider's financial, medical, and other records such as prior authorizations,
				invoices, and cost reports. The MassHealth agency conducts audits to ensure
				provider and member compliance with laws and regulations governing MassHealth.
Behavioral Health Contractor
- the
				entity contracted with EOHHS to provide, arrange for, and coordinate behavioral
				health care and other services to members on a capitated basis.
Behavioral Health Services
- mental
				health and substance use disorder services.
Billing Agent
- any individual or
				entity that contracts with a provider to act as the provider's representative
				for the preparation and submission of claims.
Board of Hearings (BOH)
- the
				designated hearing unit within the Executive Office of Health and Human
				Services Office of Medicaid.
Claim
- a request by a provider for
				payment for a medical service or product, identified in a format approved by
				the MassHealth agency, that contains information including member and provider
				information, date of service, and description of service provided.
Coverage Type
- a scope of medical
				services, other benefits, or both that are available to members who meet
				specific eligibility criteria.
Day
- a calendar day unless a business
				day is specified.
Duals Demonstration
- the MassHealth
				state Demonstration to Integrate Care for Dual Eligible Individuals, also known
				as One Care.
Duals Demonstration Dual Eligible
				Individual
- for purposes of the Duals Demonstration, a MassHealth
				member who meets all of the following criteria:
(1) is 21 through 64 years of age at the time of enrollment in
				the Duals Demonstration;
(2) is eligible for MassHealth Standard as defined in
				130 CMR 450.105(A)
				 or MassHealth CommonHealth as defined in
				130 CMR
				450.105(E);
(3) is enrolled in Medicare Parts A and B, is eligible for
				Medicare Part D, and has no other health insurance that meets the basic benefit
				level as defined in
				130 CMR
				501.001:
Definition of
				Terms
; and
(4) lives in a designated service area of an integrated care
				organization (ICO).
Eligibility Verification System (EVS)
- the member eligibility verification system accessible to providers. EVS also
				may be referred to as the Recipient Eligibility Verification System (REVS).
Emergency Aid to the Elderly, Disabled and Children
				Program (EAEDC)
- a cash assistance program administered by the
				Department of Transitional Assistance for certain residents of Massachusetts
				that also covers certain medical services. The medical services component of
				the program is administered by the MassHealth agency.
Emergency Medical Condition
- a
				medical condition, whether physical 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 the member 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)(1)(B) of the
				Social Security Act,
				42
				U.S.C. §
									1395dd(e)(1)(B).
Emergency Services
- medical services
				that are provided by a provider that is qualified to provide such services, and
				are needed to evaluate or stabilize an emergency medical condition.
Final Disposition
- a written response
				by a health insurer to a request for payment, such as a rejection notice, an
				explanation of benefits (EOB), or a similar letter, form, or other notice, by
				which the insurer either denies coverage, or acknowledges coverage and
				indicates the amount that the health insurer will pay.
Group Practice
- a legal entity that
				employs or contracts with individual practitioners who have arranged for the
				joint use of facilities, and for payment into a common account of proceeds from
				the delivery of medical services by individual practitioners within the group.
				A sole proprietorship is not a group practice. An entity that qualifies under
				the MassHealth agency's program regulations as another discreet provider type,
				such as a community health center, is not a group practice. A "participant" in
				a group practice is any owner, employee, contractor, or provider delivering
				services through the group practice.
Health Insurer
- a private or public
				entity (including Medicare) that has issued a health insurance plan or policy
				under which it has agreed to pay for medical services provided to a member.
Individual Practitioners
- physicians,
				dentists, psychologists, certified nurse practitioners, certified nurse
				midwives, physician assistants, certified registered nurse anesthetists,
				psychiatric clinical nurse specialists, clinical nurse specialists, and certain
				other licensed, registered, or certified medical practitioners.
Integrated Care Organization (ICO, also known as a
				One Care plan
) - an organization with a comprehensive network of
				medical, behavioral health care, and long term services and supports providers
				that integrates all components of care, either directly or through
				subcontracts, and has contracted with the Executive Office of Health and Human
				Services (EOHHS) and the Centers for Medicare and Medicaid Services (CMS) and
				been designated as an ICO to provide services to dual eligible individuals
				under M.G.L. c. 118E. ICOs are responsible for providing enrolled members with
				the full continuum of Medicare and MassHealth covered services.
Managed Care
- a system of primary
				care and other medical services that are provided and coordinated by a
				MassHealth managed care provider, a SCO, and ICO, or the behavioral health
				contractor in accordance with the provisions of
				130 CMR 450.117 and
				130 CMR 508.000:
				MassHealth:
Managed Care Requirements
.
Managed Care Organization (MCO)
- any
				entity with which the MassHealth agency contracts under its MCO program to
				provide, arrange for, and coordinate care and certain other medical services to
				members on a capitated basis, and is approved by the Massachusetts Division of
				Insurance as a health maintenance organization (HMO), and is organized
				primarily for the purpose of providing health care services.
MassHealth
- the medical assistance
				and benefit programs administered by the MassHealth agency pursuant to Title
				XIX of the Social Security Act (
				42 U.S.C.
				1396a
et seq
.), Title XXI of
				the Social Security Act (
				42 U.S.C.
				1397aa
et seq
.), M.G.L. c.
				118E, and other applicable laws and waivers to provide and pay for medical
				services to eligible members.
MassHealth Agency
- the Executive
				Office of Health and Human Services in accordance with the provisions of M.G.L.
				c. 118E.
MassHealth Enrollment Center (MEC)
- a
				regional office of the MassHealth agency that determines MassHealth eligibility
				of individuals and families who do not receive cash assistance (TAFDC, EAEDC,
				SSI).
MassHealth Managed Care Provider
- an
				MCO, Accountable Care Partnership Plan, Primary Care ACO, or the Primary Care
				Clinician Plan.
MCO-administered ACO
- a type of ACO
				with which the MassHealth agency contracts under its ACO program and which is
				administered through an MCO.
Medicaid
-
see
MassHealth
.
Medical Services
- medical care or
				related goods and services, including behavioral health services and long-term
				services and supports (LTSS) provided to members, paid or payable by the
				MassHealth agency.
Medicare
- a federally administered
				health insurance program for persons eligible under the Health Insurance for
				the Aged Act, Title XVIII of the Social Security Act.
Member
- a person determined by the
				MassHealth agency to be eligible for MassHealth.
One Care
-
see
Integrated Care Organization
.
Overpayment
- a payment made by the
				MassHealth agency to or for the use of a provider to which the provider was not
				entitled under applicable federal or state law or regulation.
Over-the-counter Drug
- any drug for
				which no prescription is required by federal or state law. These drugs are
				sometimes referred to as nonlegend drugs.
Party in Interest
- a person with an
				ownership or control interest.
Peer Review
- an evaluation of the
				quality, necessity, and appropriateness of medical services provided by a
				provider, to determine compliance with professionally recognized standards of
				health care or compliance with laws, rules, and regulations under which
				MassHealth is administered.
Prescription Drug
- any drug for which
				a prescription is required by applicable federal or state law or regulation,
				other than MassHealth regulations. These drugs are sometimes referred to as
				legend drugs.
Primary Care
- the provision of
				coordinated, comprehensive medical services, on both a first-contact and a
				continuous basis, to members enrolled in managed care. Services include an
				initial medical history intake, medical diagnosis and treatment, communication
				of information about illness prevention, health maintenance, and referral
				services.
Primary Care ACO
- a type of ACO with
				which the MassHealth agency contracts under its ACO program.
Primary Care Clinician (PCC) Plan
- a
				managed care option administered by the MassHealth agency through which
				enrolled members receive primary care and certain other medical services.
Provider
- an individual, group,
				facility, agency, institution, organization, or business that furnishes medical
				services and participates in MassHealth under a provider contract with the
				MassHealth agency. For purposes of applying
				130 CMR 450.235
				through
				450.240,
				the term "provider" includes formerly participating providers.
Provider Contract (Also Referred to as "Provider
				Agreement"
) - a contract for medical services between the
				MassHealth agency and a provider.
Provider Service Restrictions
-
				sanctions placed by the MassHealth agency on a provider that include, but are
				not limited to, restrictions on services for which a provider may submit claims
				to and receive payment from the MassHealth agency, and restrictions on the
				number or particular members to whom a provider may provide services.
Provider Type
- a provider
				classification specifying and limiting the kinds of medical services for which
				the provider may be paid by the MassHealth agency.
Provider under Common Ownership
- two
				or more providers in which a person or corporation has or had, at any time, an
				ownership or control interest, whether concurrently, sequentially, or
				otherwise. (
See
130 CMR
				450.221(A)(9)(a) and (b)
				).
Sanction
- an administrative penalty
				imposed by the MassHealth agency pursuant to M.G.L. c. 118E, § 37 against
				a provider found to have violated MassHealth laws, regulations, or contract
				requirements. Sanctions include, but are not limited to, administrative fines,
				provider service restrictions, suspension, and termination from participation
				in MassHealth.
Senior Care Organization (SCO)
- a
				managed care organization that participates in MassHealth under a contract with
				the MassHealth agency to provide coordinated care and medical services through
				a comprehensive network to eligible members 65 years of age or older. SCOs are
				responsible for providing enrolled members with the full continuum of
				MassHealth covered services, and for dual eligible members, the full continuum
				of MassHealth and Medicare covered services.
Statutory Prerequisite
- any license,
				certificate, permit, or other requirement imposed by state or federal law or
				regulation as a precondition to the practice of any profession or to the
				operation of any business or institution in or by which medical services are
				provided. Statutory prerequisites include, but are not limited to, licenses
				required by the Massachusetts Department of Public Health or the Massachusetts
				Department of Mental Health, licenses and certificates issued by the
				Massachusetts boards of registration, and certificates required by the
				Massachusetts Department of Public Safety.
Third Party
- any individual, entity,
				or program other than the MassHealth agency that is or may be liable to pay for
				the provision of medical services in whole or in part.
Transitional Aid to Families with Dependent
				Children (TAFDC)
- a federally funded program administered by the
				Massachusetts Department of Transitional Assistance that provides cash
				assistance to certain low-income families.
Urgent Care
- medical services that
				are not primary care, and are needed to treat a medical condition that is not
				an emergency medical condition.