Code of Massachusetts Regulations › 452 CMR - DEPARTMENT OF INDUSTRIAL ACCIDENTS › Title 452 CMR 6.00 - Utilization Review And Quality Assessment › Section 6.02 - Definitions

Current through Register 1525, July 5, 2024
Approved Utilization Review Agent
means any person or entity, insurer or self-insurer, including the Commonwealth
				of Massachusetts, which has been authorized by the DIA to perform utilization
				review.
Case Record
means the complete record
				that is maintained by the utilization review agent and pertains to the injured
				employee's industrial injury. The case record shall include all of the
				following information and documents: date of injury; date of utilization review
				request; name of claim adjuster; name, address, telephone number, and school of
				ordering practitioner; International Classification of Disease (ICD) code and
				diagnosis; name, title, and credentials of utilization review staff; health
				care service requested; treatment guideline used to determine medical
				necessity; type and category of review; and supporting medical
				documentation.
Cease and Desist Order
means a written
				notice of a violation issued by the Commissioner pursuant to 452 CMR 6.00, when
				the Commissioner determines that a utilization review agent, insurer, or
				self-insurer has failed to comply with all applicable laws, rules, regulations,
				orders, and requirements of the Commonwealth.
Clinical Reviewer
means a licensed
				health care professional who holds a non-restricted license in any
				state.
Commissioner
means the
				Commissioner/Director of the Department of Industrial Accidents (DIA).
Concurrent Review
means utilization
				review conducted during the patient's course of treatment.
Department/DIA
means Department of
				Industrial Accidents.
Guidelines
mean optimal strategies for
				patient management around which practice patterns should converge.
Health Care Services
means treatment
				services rendered to an injured employee by a provider pursuant to M.G.L. c.
				152.
Health Care Services Board
means the
				Board created by M.G.L. c. 152, § 13(3).
Injury
means personal injury as
				defined in M.G.L. c. 152, § 1(7A).
Insurer
means an entity defined in
				M.G.L. c. 152, § 1(7) and any self insured group as defined in M.G.L. c.
				152, § 25E through U.
Medical Condition
means the physical
				or mental health status of an injured employee as determined by the provider
				administering health care services.
Medical Director
means a board
				certified physician duly licensed to practice in at least one state in the
				United States, and in active practice at least eight hours per week. The OHP
				may waive the active practice requirement for otherwise qualified, licensed
				physicians with administrative experience in utilization review oversight or
				quality assessment. Each utilization review organization shall have available a
				licensed medical director to provide for clinical oversight of the utilization
				review program.
OHP
means Office of Health Policy
				which is a division of the DIA.
Practitioner
means any person who is
				licensed to practice under the laws of the jurisdiction within which such
				health care services are rendered including physicians, dentists, chiropodists,
				chiropractors, optometrists, osteopaths, physical therapists, podiatrists,
				psychologists, and other licensed medical personnel.
Preferred Provider Arrangement (PPA)
means a contract between or on behalf of an organization and health care
				provider(s), as defined by M.G.L. c. 1761,
				211 CMR 51.00:
Preferred Provider Health Plans and Workers' Compensation Preferred
				Provider Arrangements
and M.G.L. c. 152, to provide all or a specified
				portion of health care services resulting from workers' compensation claims
				against such organizations by covered persons.
Prospective Review
means utilization
				review conducted prior to the delivery of the requested medical service.
Provider
means a practitioner,
				facility, or other organization providing health care services.
Retrospective Review
means utilization
				review conducted after services have been rendered.
School
means a grouping of
				practitioners as defined by their professional degree. Schools include, but are
				not limited to, medical, physical and occupational therapy, chiropractic,
				osteopathic, allopathic, nursing and dentistry.
Utilization Review
concerns the
				quality of care provided to injured employees, including whether the service is
				appropriate and effective, the proper costs of services, and the quality of
				treatment. Appropriate service is health care service that is medically
				necessary and reasonable, and based on objective, clinical
				findings.