Code of Massachusetts Regulations › 129 CMR - HEALTH CARE QUALITY AND COST COUNCIL › Title 129 CMR 2.00 - Uniform Reporting System For Health Care Claims Data Sets › Section 2.04 - Definitions

Current through Register 1525, July 5, 2024
Unless the context indicates otherwise, the following words and phrases shall have the following meanings.
Address
. Street address, post office box numbers, apartment numbers, e-mail addresses, web universal resource locator (URL) and internet protocol (IP) address number.
Bank Account
. Any checking, savings, certificate of deposit, or any account utilized for the payment of third parties.
Capitated Services
. Services rendered by a provider through a contract in which payment are based upon a fixed dollar amount for each member on a monthly basis.
Carrier
. Any entity subject to the insurance laws and rules of Massachusetts, or subject to the jurisdiction of the commissioner of insurance that contracts or offers to provide, deliver, arrange for, pay for or reimburse any of the costs of health services, and includes an insurance company, a health maintenance organization, a nonprofit hospital services corporation, a medicalservice corporation, third party administrator or any other entity arranging for or providing insured health coverage.
Clinical Data
. Health care claims and information about health care claims for services delivered in hospitals or other setting.
Co-insurance
. The percentage a member pays toward the cost of a covered service.
Confidential Agency Data
. Data collected or produced by the Council that:
(a) Has not been released publicly;
(b) Is not a public record pursuant to M.G.L. c. 4, § 7(26) and St.2006, c. 58, § 136; and
(c) Shall not, in the opinion of the Council, be released.
Confidential Clinical Data
. Data provided to the Council that:
(a) Has not been revealed to the general public; and
(b) Relates to provision of medical or other services to a specific individual.
Confidential Financial Data
. Data provided to the Council that:
(a) Has not been revealed to the general public; and
(b) Would directly result in the data provider being placed at a competitive economic disadvantage.
Consumer Assessment of HealthCare Providers and Systems (CAHPS®)
. A family of survey tools that measure patients' experiences with ambulatory and facility-level care and with health plans.
Co-payment
. The fixed dollar amount a member pays to a health care provider at the time a covered service is provided or the full cost of a service when that is less than the fixed dollar amount.
Council
. The Health Care Quality and Cost Council, established by M.G.L. c. 6A, § 16K.
Designee
. An entity with which the Council has entered into an arrangement pursuant to which the entity performs data management and collecting functions, and under which the entity is strictly prohibited from using or releasing the information and data obtained in such a capacityforanypurposes other than those specified in the agreement.
Direct Patient Identifier
. Any information, other than case or code numbers used to create anonymous or encrypted data, that plainly discloses the identity of an individual, including:
(a) Names;
(b) Postal address information other than town or city, state and zip code;
(c) Telephone and fax numbers;
(d) Electronic mail addresses;
(e) Social security numbers;
(f) Vehicle identifiers and serial numbers;
(g) Personal internet ID addresses and URLs;
(h) Biometric identifiers, including finger and voice prints; and
(i) Personal photographic images.
Disclosure
. The act of communicating information to a person not already in possession of that information or to using information for a purpose not originally authorized.
Encryption
. A method by which the true value of data has been disguised in order to prevent the identification of persons or groups, and which does not provide the means for recovering the true value of the data.
Family
. Spouse, children, parents, siblings, and legal guardians.
Financial Data
. Information collected that includes, but is not limited to:
(a) Costs of operation;
(b) Revenues;
(c) Assets;
(d) Liabilities;
(e) Fund balances;
(f) Other income;
(g) Rates;
(h) Charges; and
(i) Units of services.
Health Care Claims Data
. Information consisting of, or derived directly from, member eligibility, medical claims, and pharmacy claims. Health Care Claims Data does not include analysis, reports, or studies containing information from health care claims data sets, if those analyses, reports, or studies have already been released in response to another request for information or as part of a general distribution of public information by the Council.
Health Care Claims Processor
. A third-party payer, third-party administrator, or carrier that provides administrative services for a plan sponsor.
Health Care Practitioner
. Physicians and all others certified, registered or licensed in the healing arts, including, but not limited to:
(a) Nurses;
(b) Podiatrists;
(c) Optometrists;
(d) Pharmacists;
(e) Chiropractors;
(f) Physical therapists;
(g) Dentists;
(h) Psychologists; and
(i) Physicians' assistants.
Healthcare Effectiveness Data and Information Set (HEDIS®)
. The set of performance measures in the managed care industry that were developed and are maintained by the National Committee for Quality Assurance (NCQA) covering various areas of measurement from general health plan information to utilization rates.
Hospita
. A licensed acute or specialty care institution.
Insured
. An individual in whose name an insurance policy is carried.
Medical Claims File
. A data file composed of service level remittance information for all non-denied adjudicated claims for each billed service including, but not limited to:
(a) Member demographics;
(b) Provider information;
(c) Charge/payment information; and
(d) Clinical diagnosis/procedure codes.
Member
. The subscriber and any spouse and/or dependent who is covered by the subscriber'spolicy.
Member Eligibility File
. A data file containing demographic information for each individual member eligible for medical or pharmacy benefits for one or more days of coverage at any time during the reporting month.
National Committee for Quality Assurance (NCQA)
. The private, not-for-profit organization that assesses and reports on the quality of the nation's managed care plans through an accreditation and performance measurement program, including quality of care, member satisfaction, access and customer service.
Non-hospital Provider
. A provider of health care services other than a hospital.
PharmacyClaims File
. A data file containing service level remittance information from all non-denied adjudicated claims for each prescription including, but not limited to:
(a) Member demographics;
(b) Provider information;
(c) Charge/payment information; and
(d) National drug codes.
Plan Sponsor
. Any persons, other than an insurer, who establishes or maintains a plan covering residents of Massachusetts, including, but not limited to, plans established or maintained by employers or jointly by one or more employers and one or more employee organizations, committee, joint board of trustees or other similar group of representatives of the parties that establish or maintain the plan.
Prepaid Amount
. The fee for the service equivalent that would have been paid by the health care claims processor for a specific service if the service had not been capitated.
Privileged Medical Information
. Information other than hospital, non-hospital health care facility, or health care claims data that identifies individual patients and that is derived from communications that were:
(a) Made for the purpose of diagnosis or treatment among a provider or health care, persons assisting the provider or patient, and a patient;
(b) Made for the purpose of payment of health care services amonga provider of health care, a health care claims processor, and a patient;
(c) Not intended to be disclosed except to persons necessary to transmit or record the communication and persons participating in the diagnosis, treatment or payment; and
(d) Not previously disclosed to the general public.
Provider
. A health care facility, health care practitioner, health product manufacturer, health product vendor or pharmacy.
Release
. To make data or information available for inspection and copying to persons other than the data provider.
Subscriber
. The certificate-holder.
Third Party Administrator
. Any persons, that, on behalf of a plan sponsor, health care services plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of the state.
Third Party Payer
. A state agency or a health insurer, nonprofithospital, medical services organization, or managed care organization licensed in the Commonwealth of Massachusetts that pays for healthcare services.