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 23.03 - General Reporting Requirements
Universal Citation: 114.5 CMR 23.00 MA Code of Regs 23.03
Current through Register 1531, September 27, 2024
(1) Annual Reports.
(a)
Each Payer shall file annually its TME by Physician Group, Physician Local
Practice Group, and Member Zip Code, and its Relative Prices for Hospitals,
Physicians, and Other Providers in accordance with the requirements of 114. 5
CMR 23.04 and 23.05.
(b) A Private
Health Care Payer is subject to the reporting requirements in 114. 5 CMR 23.00
if:
1. The Payer is a Surcharge Payer and the
Payer's Payments Subject to Surcharge placed the Payer at the company level
within the top 12 Surcharge Payers for the period October 1, 2009 through
September 30, 2010 as determined by the Division and posted on the Division's
website; or
2. The Payer 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.
3. If a Private Health
Care Payer subject to the reporting requirements of 114. 5 CMR 23.00 makes
separate surcharge payments under 114. 6 CMR 14.00 for individual plans or
clients the Payer shall file the required data for all of its plans or
clients.
(c) Public
Health Care Payers may provide data to the Division pursuant to an interagency
service agreement.
(2) Data Submission Requirements.
(a) Each Payer shall submit data directly to
the Division in electronic format. Data submissions must conform with edit
specifications as set forth in the Data Specification Manual. The Division will
notify a Payer whether the submission has been accepted or rejected. Payers
must correct and resubmit rejected data until notified that the submission has
been accepted.
(b) Each Payer's
chief executive officer or chief financial officer shall certify under pains
and penalties of perjury that all reports and records filed with the Division
are true, correct and accurate.
(c)
The Division may request that a Payer submit additional documentation of
reported TME and Relative Prices. Payers must submit documentation requested by
the Division within 15 business days from the date of the request, unless the
Division specifies a different date. The Division may, for cause, extend the
filing date of the requested information, in response to a written request for
an extension of time.
(d) The
Division may amend data specifications and filing deadlines by Administrative
Bulletin.
(3) Penalties.
(a) If a
Payer fails to submit required data to the Division on a timely basis, or fails
to correct submissions rejected because of errors, the Division shall provide
written notice to the Payer. If the Payer fails to provide the required
information within two weeks following receipt of said written notice, the
Division will take all necessary steps to enforce this provision to the fullest
extent of the law.
(b) Private
Health Care Payers that do not comply with the reporting requirements of 114. 5
CMR 21.00 are subject to a penalty of up to $1,000 per week for each week that
the Payer fails to provide the required data, up to a maximum of $50,000 in
accordance with M.G.L. c. 118G, § 6.
(c) The Division will notify the Attorney
General's Office to enforce the provisions of 114. 5 CMR 23.03(3)(a) and
(b).
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