Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 8.00 - All Payer Claims Database (apcd) And Case Mix And Charge Data Submission › Section 8.02 - Definitions

Current through Register 1525, July 5, 2024
All defined terms in
				957 CMR 8.00 are capitalized.
				As used in
				957 CMR 8.00, unless the
				context requires otherwise, the following words shall have the following
				meanings:
Acute Hospital Case Mix Databases
. The
				CHIA databases housing Case Mix Data and Charge Data, including, but not
				limited to, the outpatient emergency department database, the inpatient
				discharge database and the outpatient observation database.
APCD
. The All Payer Claims
				Database.
APCD Data
. Information submitted to
				CHIA by Payers, including, but not limited to, data regarding member
				eligibility, products, benefit plans, providers, encounters, and medical,
				pharmacy, or dental claims.
Calendar Year
. The 12-month period
				commencing January 1st and ending December
				31st.
Case Mix
. The description and
				categorization of a hospital's patient population according to criteria
				approved by CHIA including, but not limited to, primary and secondary
				diagnoses, primary and secondary procedures, illness severity, patient age and
				source of payment.
Case Mix Data
. Case specific,
				diagnostic discharge data that describe socio-demographic characteristics of
				the patient, the medical reason for the admission, treatment and services
				provided to the patient, and the duration and status of the patient's stay in
				the hospital. Case Mix data includes, but is not limited to, hospital inpatient
				data, outpatient observation data, and hospital outpatient emergency department
				data.
Charge Data
. The full, undiscounted
				total and service-specific charges billed by a hospital to the general
				public.
CHIA
. The Center for Health
				Information and Analysis.
CMS
. The federal Centers for Medicare
				& Medicaid Services.
Data
. APCD Data, Case Mix Data or
				Charge Data as defined in 957 CMR 8.02.
Data Submission Guide
. A manual that
				specifies data submission requirements including, but not limited to, required
				fields, file layouts, file components, edit specifications, instructions and
				other technical specifications.
Emergency Department
. The department
				of a hospital, or health care facility off the premises of a hospital that is
				listed on the license of the hospital and qualifies as a Satellite Emergency
				Facility under
				105 CMR 130.820
				through
				130.836, that provides
				emergency services as defined in
				105 CMR 130.020:
Satellite Unit.
For purposes of
				957 CMR 8.00, outpatient
				emergency departments include both the on-campus department of the hospitals
				that provides emergency services and any satellite emergency facilities on the
				hospital's license as defined in
				105 CMR 130.820:
Satellite Emergency Facility (SEF).
Emergency Department Visit
. Any visit
				by a patient to an emergency department that results in registration at the
				Emergency Department but does not result in an outpatient observation stay nor
				the inpatient admission of the patient at the reporting facility. An Emergency
				Department visit occurs even if the only service provided to a registered
				patient is triage or screening.
Encounter Data
. Data relating to the
				treatment or services rendered by a provider to a patient.
Health Care Claims Data
. Information
				consisting of, or derived directly from, member eligibility information,
				medical claims, pharmacy claims, dental claims, and other data submitted by
				health care payers to CHIA.
Health Care Services
. Supplies, care
				and services of a medical, 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 Plan Information
. Information
				submitted to CHIA by Payers, including, but not limited to, aggregate data on
				membership and financials by insurance products and plan design, administrative
				expenses, benefit levels, premiums, member utilization and medical expenses,
				provider price variation and provider payment arrangements.
Hospital
. Any hospital licensed by the
				Department of Public Health in accordance with the provisions of M.G.L. c. Ill,
				§ 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.
Hospital Fiscal Year
. The 12-month
				period during which a hospital keeps its accounts and which ends in the
				calendar year by which it is identified. For Case Mix submissions this is
				October 1st through September
				30th.
Integrated Care Organization (ICO)
. A
				comprehensive network of medical, behavioral-health care, and long-term
				services and support providers that integrates all components of care, either
				directly or through subcontracts, and has been designated as an ICO to provide
				services to dual eligible individuals under M.G.L. c. 118E. ICOs are
				responsible for providing enrollees with the full continuum of Medicare and
				MassHealth covered services.
Managed Care Organization
. A managed
				care organization, as defined in
				42
				CFR 438.2, and any eligible health insurance
				plan, as defined in M.G.L. c. 118H, § 1, that contracts with MassHealth or
				the Commonwealth Health Insurance Connector Authority; provided, however, that
				a managed care organization shall not include a senior care organization, as
				defined in M.G.L. c. 118E, §9D.
Medical Record Number
. The unique
				number assigned to each patient within a hospital that distinguishes the
				patient and the patient's hospital record(s) from all others in that
				institution.
Member
. A person who holds an
				individual contract or a certificate under a group arrangement contracted with
				a Payer.
Member Eligibility File
. A file that
				includes data about a person who receives health care coverage from a payer,
				including but not limited to subscriber and member identifiers; member
				demographics; race, ethnicity and language information; plan type; benefit
				codes; enrollment start and end dates; and behavioral and mental health,
				substance abuse and chemical dependency and prescription drug benefit
				indicators.
Observation Services
. Those services
				furnished on a hospital's premises that are reasonable and necessary to further
				evaluate the patient's condition and provide treatment to determine the need
				for possible admission to the hospital. These services include the use of a bed
				and periodic monitoring by a hospital's physician, nursing and other staff. If
				the patient is admitted, observation services are reported as inpatient
				observation services and included in the inpatient discharge record. If the
				patient is not admitted, observation services are reported as outpatient
				observation services and included in the outpatient observation stay
				record.
Payer
. A Private Health Care Payer and
				a Public Health Care Payer.
Private Health Care Payer
. A private
				entity that contracts to provide, deliver, arrange for, pay for, or reimburse
				any of the costs of Health Care Services. A Private Health Care Payer includes
				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, to the extent
				allowable under federal law governing health care provided by employers to
				employees, a health maintenance organization licensed under M.G.L. c. 176G, an
				ICO, an SCO, and third-party administrators.
Public Health Care Payer
. The Medicaid
				program established in M.G.L. c. 118E; any carrier or other entity that
				contracts with the office of Medicaid or the Commonwealth Health Insurance
				Connector to pay for or arrange for the purchase of health care services on
				behalf of individuals enrolled in health coverage programs under Titles XIX or
				XXI, or under the Connector Care Health Insurance program, including prepaid
				health plans subject to the provisions of St. 1997, c. 47, § 28; the Group
				Insurance Commission established under M.G.L. c. 32A; and any city or town with
				a population of more than 60,000 that has adopted M.G.L. c. 32B.
Quarter
. The three-month period
				including January 1st through March
				31st; April 1st through
				June 30th; July 1st
				through September 30th; and October
				1st through December
				31st.
Self-funded Employee Plan
. An
				employer-sponsored health benefit plan, where the employer is liable for the
				incurred costs of the Health Care Services for its employees and plan members
				and the administrative service fees. A Self-funded Employee Plan shall not
				include a governmental plan as defined in Section 414(d), Internal Revenue Code
				or a non-electing church plan as described in Section 410 (d), Internal Revenue
				Code.
Senior Care Organization (SCO)
. A
				comprehensive network of medical, health care and social service providers that
				integrates all components of care, either directly or through subcontracts.
				Senior Care Organizations are responsible for providing enrollees with the full
				continuum of Medicare and MassHealth covered services.
Website
. The website of the Center for
				Health Information and Analysis located at
www.mass.gov/chia
.