Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.02 - Definitions

Current through Register 1525, July 5, 2024
All defined terms in
				957 CMR 2.00 are
				capitalized. As used in
				957 CMR 2.00, unless
				the context requires otherwise, the following terms shall have the
				following meanings:
Allowed Claims
. Paid medical
				claims plus related Member liabilities including, but not limited to,
				co-pays, co-insurance, and deductibles.
Alternative Payment Methods
				(APM)
. Payment methods not based solely on
				Fee-for-service reimbursements. Alternative payment methods may
				include, but are not be limited to, shared savings arrangements,
				bundled payments and global payments. Alternative payment
				methodologies may also include Fee-for-service payments, which are
				settled or reconciled with a bundled or global payment.
Ambulatory Surgical Center
.
				Any distinct entity that operates exclusively to provide surgical
				services to patients not requiring hospitalization and meets the
				requirements of the federal Health Care Financing Administration for
				participation in the Medicare program.
Behavioral Health Expenses
.
				Payments to Providers, including payer paid and Member cost share
				amounts, for the provision of behavioral health services.
Calendar Year
. The period
				beginning January 1st and ending December
				31st.
Center
. The Center for
				Health Information and Analysis established under M.G.L. c.
				12C.
Data Specification
				Manual
. The
Data Specification Manual
contains data submission requirements including, but not
				limited to, required fields, file layouts, file components, edit
				specifications, instructions and other technical
				specifications.
Fee-for-service
. A payment
				mechanism in which all reimbursable health care activity is described
				and categorized into discrete and separate units of service and each
				Provider is separately reimbursed for each discrete service rendered
				to a patient. Fee-for-service payments include Diagnosis-related
				Groups (DRGs),
per diem
payments, fixed procedure
				code-based fee schedule (including Ambulatory Payment Classification
				(APC)), and discounted charges-based payments.
Freestanding
. Existing
				independently or physically separated from another health care
				facility and administered by separate staff with separate
				records.
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, behavioral health, substance
				use disorder, mental health, 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
				957
				CMR 2.04.
Hospital
. Any hospital
				licensed by the Department of Public Health in accordance with the
				provisions of M.G.L. c. 111, § 51, the teaching hospital of the
				University of Massachusetts Medical School, and any psychiatric
				facility licensed in accordance with M.G.L. c. 19, § 19, or any
				public health care facility.
Incurred but Not Reported
				(IBNR)
. Health Care Payer liabilities for claims or
				non-claims that, as of the date of data extraction, are anticipated
				but have not been reported to the Payer, have been reported but not
				yet adjudicated, have been adjudicated but not fully paid, or are in
				dispute.
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 Due to Financial
				Performance
. Includes adjustments to a contracted
				payment amount, or additions to a base payment amount, or any other
				payments that are based solely on the achievement of financial or
				cost-based measures.
Payments Due to Quality
				Performance
. Includes adjustments to a contracted
				payment amount, or additions to a base payment amount, or any other
				payments that are based on the achievement of quality measures
				(
e.g
., quality, access, and/or patient
				experience).
Per Member per Month (PMPM)
.
				An adjustment made by dividing an annual amount by Member
				Months.
Pharmacy Benefit Manager
				(PBM)
. A Third Party Administrator of prescription drug
				coverage programs. A PBM includes an entity that provides any of the
				following services on behalf of Payers or self-insured employer
				plans: pharmacy claims processing, pharmacy network contracting, drug
				formulary management, or manufacturer drug rebate contracting.
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 patient care services.
Prescription Drug Rebates
.
				Any rebates, discounts, and other price concessions (including
				concessions from price protection and hold harmless contract clauses)
				provided by pharmaceutical manufacturers for prescription drugs with
				specified dates of fill, excluding manufacturer-provided fair market
				value
bona fide
service fees.
Primary Care Expenses
.
				Payments to Providers, including payer paid and Member cost share
				amounts, for the provision of primary care services.
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 also include any carrier
				or Third Party Administrator that contracts with the office of
				Medicaid, the Massachusetts Health 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 ConnectorCare
				Health Insurance program, Medicaid managed care organizations,
				Medicare Advantage Plans, 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.
Provider Organization
. 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
				Providers in contracting with carriers for the payments of Heath Care
				Services including, but not limited to, physician organizations,
				physician-hospital organizations, independent practice associations,
				provider networks, accountable care organizations and any other
				organization that contracts with carriers for payment for 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.
Registered Provider
				Organization
. A Provider Organization that has been
				registered in accordance with M.G.L. c. 6D, § 11.
Relative Prices
. The
				contractually negotiated amounts paid to Massachusetts Providers by
				each 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
				957 CMR
				2.05.
Surcharge Payer
. An
				individual or entity, including a managed care organization, that
				pays for or arranges for the purchase of Health Care Services
				provided by Hospitals and Ambulatory Surgical Center services
				provided by Ambulatory Surgical Centers; provided however, that the
				term "Surcharge Payer" shall not include:
(a) Title XVIII and Title XIX programs and their
				beneficiaries or recipients;
(b) other governmental programs of public assistance
				and their beneficiaries or recipients; and
(c) the workers' compensation program established
				pursuant to M.G.L. c. 152.
Third Party Administrator
.
				An entity who, on behalf of a Payer 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 include any entity with claims data,
				eligibility data, provider files, and other information relating to
				health care provided to residents of the Commonwealth and Health Care
				Services 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.