Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers
Section 52.17 - Material to Be Provided to the Office of Patient Protection
Universal Citation: 211 MA Code of Regs 211.52
Current through Register 1531, September 27, 2024
(1) A Carrier shall provide the following to the Office of Patient Protection at the same time the Carrier provides such material to the Bureau of Managed Care:
(a) A
copy of every Evidence of Coverage and amendments thereto offered by the
Carrier.
(b) A copy of the Provider
directory described in
211
CMR 52.15.
(c) A copy of the materials specified in
211
CMR 52.14.
(2) A Carrier shall provide the following to the Office of Patient Protection by no later than April 1st:
(a) A list of
sources of independently published information assessing Insured satisfaction
and evaluating the quality of Health Care Services offered by the
Carrier.
(b) A report of the
percentage of physicians and Nurse Practitioners and Physician Assistants who
voluntarily and involuntarily terminated participation contracts with the
Carrier during the previous calendar year for which such data has been compiled
and the three most common reasons for voluntary and involuntary Provider
disenrollment;
1. For the purposes of
211
CMR 52.16(2)(b), Carriers
shall exclude physicians, Nurse Practitioners, and Physician Assistants who
have moved from one physician and/or Nurse Practitioner or Physician Assistant
group to another but are still under contract with the Carrier.
2. For the purposes of
211
CMR 52.16(2)(b),
"voluntarily terminated" means that the physician, Nurse Practitioner, or
Physician Assistant terminated the contract with the Carrier.
3. For the purposes of
211
CMR 52.16(2)(b),
"involuntarily terminated" means that the Carrier terminated its contract with
the physician, Nurse Practitioner, or Physician Assistant;
(c) The percentage of premium revenue
expended by the Carrier for Health Care Services provided to Insureds for the
most recent year for which information is available;
(d) A report detailing, for the previous
calendar year, the total number of:
1. filed
Grievances, Grievances that were approved internally, Grievances that were
denied internally, and Grievances that were withdrawn before resolution;
and
2. external appeals pursued
after exhausting the internal Grievance process and there solution of all such
external appeals. The report shall identify for each such category, to the
extent such information is available, the demographics of such Insureds, which
shall include, but need not be limited to, race, gender and age; and
(e) A report detailing for the
previous calendar year the total number of:
1.
medical or surgical claims submitted to the Carrier;
2. medical or surgical claims denied by the
Carrier;
3. mental health or
substance use disorder claims submitted to the Carrier;
4. mental health or substance use disorder
claims denied by the Carrier; and
5. medical or surgical claims and mental
health or substance use disorder claims denied by the Carrier because:
a. the Insured failed to obtain pre-treatment
authorization or referral for services;
b. the service was not Medically
Necessary;
c. the service was
experimental or investigational;
d.
the Insured was not covered or eligible for benefits at the time services
occurred;
e. the Carrier does not
cover the service or the Provider under the Insured's plan;
f. duplicate claims had been
submitted;
g. incomplete claims had
been submitted;
h. coding errors
had occurred; or
i. of any other
specified reason.
(f) A Carrier that provides specified
services through a workers' compensation preferred Provider arrangement shall
be deemed to have meet the requirements of
211
CMR 52.16(1)(a) through (c) and (2)(c) through
(e).
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
