Code of Massachusetts Regulations
114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY
Title 114.5 CMR 23.00 - PAYER REPORTING OF TOTAL MEDICAL EXPENSES AND RELATIVE PRICES
Section 23.02 - Definitions

The following terms as used in 114.5 CMR 23.00 have the following meanings, except where the context clearly indicates otherwise:

Allowed Claims. Paid medical claims plus related Member liabilities, including, but not limited to, co-pays, co-insurance, and deductibles.

Ancillary Services. Non-routine services for which charges are customarily made in addition to routine charges, that include, but are not limited to, laboratory, diagnostic and therapeutic radiology, surgical services, and physical, occupational, or speech-language therapy.

Calendar Year. The period beginning January 1st and ending December 31st.

Commissioner. The Commissioner of the Division of Health Care Finance and Policy.

Data Specification Manual. The Data Specification Manual contains data submission requirements, including, but not limited to, required fields, file layouts, file components, edit specifications, and other technical specifications.

Division. The Division of Health Care Finance and Policy established under M.G.L. c. 118G.

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, 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 114.5 CMR 23.04.

Hospital. A hospital licensed by the Department of Public Health in accordance with the provisions of M.G.L. c. 111.

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 Subject to Surcharge. Payments subject to the surcharge established by M.G.L. c. 118G, § 38, including payments defined under 114.6 CMR 14.05(1)(b) and excluding payments defined under 114.6 CMR 14.05(1)(c).

Pediatric Physician Practice. A physician group practice in which at least 75% of its patients are children up to the age of 18.

Per Member Per Month (PMPM). An adjustment made by dividing an annual amount by Member Months.

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 primary care.

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 include any carrier or Third Party Administrator that contracts with the office of Medicaid, the Commonwealth Health Insurance 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 Commonwealth Care Health Insurance program, Medicaid managed care organizations, 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.

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.

Relative Prices. The contractually negotiated amounts paid to Massachusetts providers by each Private and Public 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 114.5 CMR 23.05.

Routine Services. The regular room and board services, daily nursing care, minor medical and surgical supplies, and the use of equipment and facilities.

Surcharge. The surcharge on payments made to Hospitals and Ambulatory Surgical Centers established by M.G.L. c. 118G, § 38 and 114.6 CMR 14.00.

Surcharge Payer. An individual or entity that:

(a) makes payments for the purchase of health care Hospital Services and Ambulatory Surgical Center Services; and

(b) meets the criteria set forth in 114.6 CMR 14.05(1)(a).

Third Party Administrator. An entity who, on behalf of a health insurer 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 also include pharmacy benefit managers and any other entity with claims data, eligibility data, provider files, and other information relating to health care provided to residents of the Commonwealth and health care 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.