Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers
Section 52.02 - Definitions
Current through Register 1531, September 27, 2024
As used in 211 CMR 52.00, the following words mean:
Accreditation. A written determination by the Bureau of Managed Care of compliance with M.G.L. c. 176O, 211 CMR 52.00 and 958 CMR 3.000: Health Insurance Consumer Protection.
Actively Practices. A Health Care Professional who regularly treats or manages patients in a clinical setting.
Administrative Disenrollment. A change in the status of an Insured whereby the Insured remains with the same Carrier but his or her membership may appear under a different identification number. Examples of an Administrative Disenrollment are a change in employers, a move from an individual plan to a spouse's plan, or any similar change that may be recorded by the Carrier as both a disenrollment and an enrollment.
Adverse Determination. A determination, based upon a review of information provided, by a Carrier or its designated Utilization Review Organization, to deny, reduce, modify, or terminate an admission, continued inpatient stay, or the availability of any other Health Care Services, forfailure to meet the requirements for coverage based on Medical Necessity, appropriateness of health care setting and level of care, or effectiveness, including a determination that a requested or recommended Health Care Service or treatment is experimental or investigational. An Adverse Determination includes any denial of access to an out-of-Network Provider at an in-Network benefit level where there is an oral or written assertion by an Insured or treating Provider that a Carrier's preferred Provider Network does not have Providers who are able and available to treat the patient's specific condition and the preferred Provider Network is therefore not adequate to deliver the needed benefits at the preferred Provider level.
Alternative Payment Contract. Any contract between a Carrier and a Provider or Provider organization that utilizes alternative payment methodologies, which are methods of payment that are not solely based on fee-for-service reimbursements and that may include, but is not limited to, shared savings arrangements, bundled payments, global payments, and fee-for-service payments that are settled or reconciled with a bundled or global payment.
Ambulatory Review. Utilization Review of Health Care Services performed or provided in an out patient setting, including, but not limited to, outpatient or ambulatory surgical, diagnostic and therapeutic services provided at any medical, surgical, obstetrical, psychiatric and chemical dependency Facility, as well as other locations such as laboratories, radiology facilities, Provider offices and patient homes.
Asynchronous or Asynchronous Telehealth. An exchange of information regarding a patient that does not occur in real time, including but not limited to the secure collection and transmission of a patient's medical information, clinical data clinical images, laboratory results, or a self-reported medical history.
Behavioral Health Manager. A company, organized under the laws of the Commonwealth of Massachusetts or organized under the laws of another state and qualified to do business in the Commonwealth, that has entered into a contractual arrangement with a Carrier to provide or arrange for the provision of behavioral, substance use disorder and mental Health Services to voluntarily enrolled members of the Carrier.
Behavioral Health Services. Care and services for the evaluation, diagnosis, treatment, consultation, prescribing, monitoring or management of mental health, developmental, or substance use disorders. Such care and services may be provided by any Health Care Professional for whom such services are within the scope of licensure for such Health Care Professional. Behavioral Health Services shall also include but not be limited to Partial Hospital Programs and Intensive Outpatient Programs.
Behavioral Health Specialty Care. Behavioral Health Services dedicated to treating particular behavioral health conditions. A behavioral health Provider should be listed as providing specific Behavioral Health Specialty Care when they regularly provide the care.
Bureau of Managed Care or Bureau. The bureau in the Division of Insurance established by M.G.L. c. 176O, § 2.
Capitation. A set payment per patient per unit of time made by a Carrier to a licensed Health Care Professional, Health Care Provider group, or organization that employs or utilizes services of Health Care Professionals to cover a specified set of services and administrative costs without regard to the actual number of services provided.
Carrier. An insurer licensed or otherwise authorized to transact accident or health insurance under M.G.L. c. 175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a nonprofit medical service corporation organized under M.G.L. c. 176B; a health maintenance organization organized under M.G.L. c. 176G; and an organization entering into a preferred Provider arrangement under M.G.L. c. 176I, but not including an employer purchasing coverage or acting on behalf of its employees or the employees of one or more subsidiaries or affiliated corporations of the employer. Unless otherwise noted, the term "Carrier" shall not include any entity to the extent it offers a policy, certificate, or contract that is not a health benefit plan as defined in M.G.L. c. 176J, § 1.
Case Management. A coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.
Chronic Disease Management. Care and services for the management of chronic conditions, including
(a) conditions, defined by the federal Centers for Medicare and Medicaid Services that include, but are not limited to, diabetes, chronic obstructive pulmonary disease, asthma, congestive heart failure, hypertension, history of stroke, cancer, and coronary artery disease;
(b) congenital anomalies and hereditary conditions; and
(c) other chronic conditions that last one year or more and require ongoing medical attention or limit activities of daily living or both.
Clean and Complete Credentialing Application. A credentialing application which is appropriately signed and dated by the Provider, and which includes all of the applicable information requested from the Provider by the Carrier.
Clinical Peer Reviewer. A physician or other Health Care Professional, other than the physician or other Health Care Professional who made the initial decision, who holds a nonrestricted license from the appropriate professional licensing board in Massachusetts, current board certification from a Specialty board approved by the American Board of Medical Specialties or of the Advisory Board of Osteopathic Specialists from the major areas of clinical services or, for non-physician Health Care Professionals, the recognized professional board for their Specialty, who Actively Practices in the Same or Similar Specialty as typically manages the medical condition, procedure or treatment under review, and whose compensation does not directly or indirectly depend upon the quantity, type or cost of the services that such person approves ordenies.
Clinical Review Criteria. The written screening procedures, decisions, abstracts, clinical protocols and practice guidelines used by a Carrier to determine the Medical Necessity and appropriateness of Health Care Services.
Commissioner. The Commissioner of Insurance, appointed pursuant to M.G.L. c. 26, § 6, or his or her designee.
Complaint.
(a) any Inquiry made by or on behalf of an Insured to a Carrier or Utilization Review Organization that is not explained or resolved to the Insured's satisfaction within three business Days of the Inquiry;
(b) any matter concerning an Adverse Determination; or
(c) in the case of a Carrier or Utilization Review Organization that does not have an internal Inquiry process, a Complaint means any Inquiry.
Concurrent Review. Utilization Review conducted during an Insured's inpatient hospital stay or course of treatment.
Cost Sharing or Cost-sharing. Includes deductibles, coinsurance, copayments, or similar charges required of an Insured, but does not include premiums, balance-billing amounts for out-of-Network Providers, or spending for non-covered Benefits.
Covered Benefits or Benefits. Health Care Services to which an Insured is entitled under the terms of the Health Benefit Plan.
Days. Calendar days, unless otherwise specified in 211 CMR 52.00; provided, that computation of days specified in 211 CMR 52.00 begins with the first day following the referenced action, and provided further that if the final day of a period specified in 211 CMR 52.00 falls on a Saturday, Sunday or state holiday, the final day of the period will be deemed to occur on the next working day.
Dental Benefit Plan. A policy, contract, certificate or agreement of insurance entered into, offered or issued by a Dental Carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs solely for Dental Care Services.
Dental Care Professional. A dentist or other dental care practitioner licensed, accredited or certified to perform specified Dental Services consistent with the law.
Dental Care Provider. A Dental Care Professional or Facility licensed to provide Dental Care Services.
Dental Care Services or Dental Services. Services for the diagnosis, prevention, treatment, cure or relief of a dental condition, illness, injury or disease.
Dental Carrier. An entity that offers a policy, certificate or contract that provides coverage solely for Dental Care Services and is: an insurer licensed or otherwise authorized to transact health insurance under M.G.L. c. 175; a nonprofit hospital service corporation organized under M. G.L. c. 176A; a nonprofit medical service corporation organized under M.G.L. c. 176B; a dental service corporation organized under M.G.L. c. 176E, or an organization entering into a preferred Provider arrangement under M.G.L. c. 176I, but not including an employer purchasing coverage or acting on behalf of its employees or the employees or one or more subsidiaries or affiliated corporations of the employer, that offers a policy, certificate or contract that provides coverage solely for Dental Care Services.
Discharge Planning. The formal process for determining, prior to discharge from a Facility, the coordination and management of the care that an Insured receives following discharge from a Facility.
Division. The Division of Insurance established pursuant to M.G.L. c. 26, § 1.
Emergency Medical Condition. A medical condition, whether physical, behavioral, related to substance use disorder, or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of an Insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in § 1867(e)(l)(B) of the Social Security Act, 42 U.S.C.§ 1395dd(e)(1)(B).
Evidence of Coverage. Any certificate, contract or agreement of health insurance including riders, amendments, endorsements and any other supplementary inserts or a summary plan description pursuant to § 104(b)(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1024(b), issued to an Insured specifying the Benefits to which the Insured is entitled. For workers' compensation preferred Provider arrangements, the Evidence of Coverage will be considered to be the information annually distributed pursuant to 211 CMR 51.04(3)(i)1. through 3.
Facility. A licensed institution providing Health Care Services or a health care setting including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
Finding of Neglect. A written determination by the Commissioner that a Carrier has failed to make and file the materials required by M.G.L. c. 176O or 211 CMR 52.00 in the form and within the time required.
Grievance. Any oral or written Complaint submitted to the Carrier that has been initiated by an Insured, or on behalf of an Insured with the consent of the Insured, concerning any aspect or action of the Carrier relative to the Insured including, but not limited to, review of Adverse Determinations regarding scope of coverage, denial of services, rescission of coverage, quality of care and administrative operations, in accordance with the requirements of M.G.L. c. 176O and 958 CMR 3.000: Health Insurance Consumer Protection.
Health Benefit Plan. A policy, contract, certificate or agreement of insurance entered into, offered or issued by a Carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of Health Care Services. Unless otherwise noted, Health Benefit Plan shall not include any policy, certificate, or contract that is not a health benefit plan as defined in M.G.L. c. 176J, § 1.
Health Care Professional. A physician or other health care practitioner licensed, accredited or certified to perform specified Health Services consistent with the law.
Health Care Provider or Provider. A Health Care Professional or Facility.
Health Care Services or Health Services. Services for the evaluation, consultation, prescribing, diagnosis, prevention, treatment, management, cure or relief of a physical, behavioral, substance use disorder or mental health condition, illness, injury or disease.
HMO. A health maintenance organization licensed pursuant to M.G.L. c. 176G.
Incentive Plan. Any compensation arrangement between a Carrier and Health Care Professional or Licensed Health Care Provider Group or organization that employs or utilizes services of one or more licensed Health Care Professionals that may directly or indirectly have the effect of reducing or limiting specific services furnished to Insureds of the organization. Incentive Plan shall not mean contracts that involve general payments such as Capitation payments or shared risk agreements that are made with respect to Health Care Professionals or Providers, or Health Care Professional groups or Provider groups which are made with respect to groups of Insureds if such contracts, which impose risk on such Health Care Professionals or Providers or Health Care Professional groups or Provider groups for the cost of medical care, services and equipment provided or authorized by another Health Care Professional or Provider or by another Health Care Professional group or Provider group, comply with 211 CMR 52.00.
Inquiry. Any communication by or on behalf of an Insured to the Carrier or Utilization Review Organization that has not been the subject of an Adverse Determination and that requests redress of an action, omission or policy of the Carrier.
Insured. An enrollee, covered person, Insured, member, policy holder or subscriber of a Carrier, including a Dental or Vision Carrier, including an individual whose eligibility as an Insured of a Carrier is in dispute or under review, or any other individual whose care may be subject to review by a Utilization Review program or entity as described under the provisions of M.G.L. c. 176O, 211 CMR 52.00 and 958 CMR 3.000: Health Insurance Consumer Protection.
Internet Website. Includes, but shall not be limited to, an internet website, an intranet website, a web portal, or electronic mail.
JCAHO. The Joint Commission on Accreditation of Health Care Organizations.
Licensed Health Care Provider Group. A partnership, association, corporation, individual practice association, or other group that distributes income from the practice among members. An individual practice association is a Licensed Health Care Provider Group only if it is composed of individual Health Care Professionals and has no subcontracts with Licensed Health Care Provider Groups.
Limited Health Services. Pharmaceutical services, and such other services as may be determined by the Commissioner to be Limited Health Services. Limited Health Services shall not include hospital, medical, surgical or emergency services, except as such services are provided in conjunction with the Limited Health Services set forth in the preceding sentence.
Limited Network Plan. A Limited Network plan as defined in 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks.
Managed Care Organization or MCO. A Carrier subject to M.G.L. c. 176O.
Material Change. A modification to any of a Carrier's, including a Dental or Vision Carrier's, procedures or documents required by 211 CMR 52.00 that substantially affects the rights or responsibilities of:
(a) an Insured;
(b) a Carrier, including a Dental or Vision Carrier; and/or
(c) a Health, Dental, or Vision Care Provider.
Medical Necessity or Medically Necessary. Health Care Services that are consistent with generally accepted principles of professional medical practice as determined by whether:
(a) the service is the most appropriate available supply or level of service for the Insured in question considering potential benefits and harms to the individual;
(b) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or
(c) for services and interventions not in widespread use, is based on scientific evidence.
National Accreditation Organization. JCAHO, NCQA, URAC or any other national Accreditation entity approved by the Division that accredits Carriers that are subject to the provisions of M.G.L. c. 176O and 211 CMR 52.00.
NCQA. The National Committee for Quality Assurance.
NCQA Standards. The Standards and Guidelines for the Accreditation of Health Plans published annually by the NCQA.
Network or Provider Network. A group of health, Dental or Vision Care Providers who contract with a Carrier, including a Dental or Vision Carrier, or affiliate to provide health, Dental or Vision Care Services to Insureds covered by any or all of the Carrier's, including a Dental or Vision Carrier's or affiliate's, plans, policies, contracts or other arrangements. Network shall not mean those Participating Providers who provide services to subscribers of a nonprofit hospital service corporation organized under M.G.L. c. 176A, or a nonprofit medical service corporation organized under M.G.L. c. 176B.
Nongatekeeper Preferred Provider Plan. An insured preferred Provider plan approved for offer under M.G.L. c. 176I which offers preferred Benefits when a covered person receives care from preferred Network Providers but does not require the Insured to designate a Primary Care Provider to coordinate the delivery of care or receive referrals from the Carrier or any Network Provider as a condition of receiving Benefits at the preferred benefit level.
Nurse Practitioner. A registered nurse who holds authorization in advanced nursing practice as a nurse practitioner under M.G.L. c. 112, § 80B.
Office of Patient Protection. The office within the Health Policy Commission established by M.G.L. c. 6D, § 16, responsible for the administration and enforcement of M.G.L. c. 176O, §§ 13, 14, 15 and 16.
Participating Provider. A Provider who, under a contract with the Carrier, including a Dental or Vision Carrier, or with its contractor or subcontractor, has agreed to provide health, Dental or Vision Care Services to Insureds with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the Carrier, including a Dental or Vision Carrier.
Physician Assistant. A person who is a graduate of an approved program for the training of physician assistants who is supervised by a registered physician in accordance with M.G.L. c. 112, § 9C through 9H and who has passed the Physician Assistant National Certifying Exam or its equivalent.
Preventive Health Services. Any periodic, routine, screening or other services designed for the prevention and early detection of illness that a Carrier is required to provide pursuant to Massachusetts or federal law.
Primary Care Provider. A Health Care Professional qualified to provide general medical care for common health care problems, who supervises, coordinates, prescribes, or otherwise provides or proposes Health Care Services; initiates referrals for Specialty Care; and maintains continuity of care within the scope of his or her practice. A Primary Care Provider may include but not be limited to medical doctors and Nurse Practitioners and Physician Assistants who concentrate in primary care, pediatric primary care, and/or gynecological and reproductive health.
Primary Care Services. Services delivered by a Primary Care Provider.
Prospective Review. Utilization Review conducted prior to an admission or a course of treatment. Prospective Review shall include any pre-authorization and pre-certification requirements of a Carrier or Utilization Review Organization.
Regional Network Plan. A Regional Network Plan as defined in 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks.
Religious Non-medical Provider. A Provider who provides no medical care but who provides only religious non-medical treatment or religious non-medical nursing care.
Retrospective Review. Utilization Review of Medical Necessity that is conducted after services have been provided to a patient. Retrospective Review shall not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment.
Same or Similar Specialty. The Health Care Professional has similar credentials and licensure as those who typically provide the treatment in question and has experience treating the same condition that is the subject of the Grievance. Such experience shall extend to the treatment of children in a Grievance involving a child where the age of the patient is relevant to the determination of whether a requested service or supply is Medically Necessary.
Second Opinion. An opportunity or requirement to obtain a clinical evaluation by a Health Care Professional other than the Health Care Professional who made the original recommendation for a proposed Health Service, to assess the clinical necessity and appropriateness of the initial proposed Health Service.
Service Area. The geographical area as approved by the Commissioner within which the Carrier, including a Dental or Vision Carrier, has developed a Network of Providers to afford adequate access to members for covered Health, Dental or Vision Services.
Site of Service Plan. An insured Health Benefit Plan where access to certain specified Network Providers or access to care in certain specified settings may only be available when the Carrier determines that it is medically necessary to receive covered care from these certain Providers or the certain settings. The Utilization Review processes and Medical Necessity criteria used are required to meet the relevant requirements of 211 CMR 52.00 and any requirements as determined by the Commissioner. Whenever a request for services provided by certain specified Network Providers for care at certain specified locations is denied, Carriers with Site of Service Plans are to follow all required protocols for Adverse Determination notices and appeals as required under 211 CMR 52.00.
Specialty or Specialty Care. Health Care services dedicated to a specific branch of medicine or all Health Care services not considered primary care. Patients can be referred to a specialist by a Primary Care Provider for disease-specific care that requires expert support.
Telehealth. The use of synchronous or asynchronous audio, video, electronic media or other telecommunications technology including, but not limited to:
Terminally Ill or Terminal Illness. An illness that is likely, within a reasonable degree of medical certainty, to cause one's death within six months, or as otherwise defined in section 1861(dd)(3)(A) of the Social Security Act, 42 U.S.C. § 1395x(dd)(3)(A).
Tiered Network Plan. A Tiered Network Plan as described in 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks.
URAC. The American Accreditation Health Care Commission/URAC, formerly known as the Utilization Review Accreditation Commission.
Utilization Review. Set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, Health Care Services, procedures or settings. Such techniques may include, but are not limited to, Ambulatory Review, Prospective Review, Second Opinion, certification, Concurrent Review, Case Management, Discharge Planning or Retrospective Review.
Utilization Review Organization. An entity that conducts Utilization Review under contract with or on behalf of a Carrier, but does not include a Carrier performing Utilization Review for its own Health Benefit Plans. A Behavioral Health Manager is considered a Utilization Review Organization.
Vision Benefit Plan. A policy, contract, certificate or agreement of insurance entered into, offered or issued by a Carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs solely for Vision Care Services.
Vision Care Professional. An ophthalmologist, optometrist or other practitioner licensed, accredited or certified to perform specified Vision Services consistent with the law.
Vision Care Provider. A Vision Care Professional; or a Facility licensed to perform and provide Vision Care Services.
Vision Care Services or Vision Services. Services for the diagnosis, prevention, treatment, cure or relief of a vision condition, illness, injury or disease.
Vision Carrier. An entity that offers a policy, certificate or contract that provides coverage solely for Vision Care Services and is: an insurer licensed or otherwise authorized to transact accident or health insurance under M.G.L. c. 175; an optometric service corporation organized under M.G.L. c. 176F, or an organization entering into a preferred Provider arrangement under M.G.L. c. 176I, but not including an employer purchasing coverage or acting on behalf of its employees or the employees of one or more subsidiaries or affiliated corporations of the employer, that offers a policy, certificate or contract that provides coverage solely for Vision Care Services.
Visit. A scheduled, urgent, or emergency encounter between a covered patient and a Health Care Professional, whether conducted within the Health Care Professional's office, another physical location or conducted via synchronous or Asynchronous Telehealth, to evaluate, diagnose, consult, treat, conduct clinical trials, prescribe, manage or monitor a covered medical, oral health or behavioral health condition. Within a Visit, the Health Care Professional will review patient history, examine the patient's condition, and exercise medical judgment in treating a patient. In the case of Telehealth Visits, a Health Care Professional must receive consent from a patient that the encounter will constitute a Visit and may be subject to Health Benefit Plan Cost-sharing if the Health Care Professional ever seeks reimbursement for the Telehealth encounter from either the patient or the patient's Carrier.
