Code of Massachusetts Regulations
957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS
Title 957 CMR 2.00 - Payer Data Reporting
Section 2.02 - Definitions
All defined terms in 957 CMR 2.00 are capitalized. As used in 957 CMR 2.00, unless the context requires otherwise, the following terms shall have the following meanings:
Allowed Claims. Paid medical claims plus related Member liabilities including, but not limited to, co-pays, co-insurance, and deductibles.
Alternative Payment Methods (APM). Payment methods not based solely on Fee-for-service reimbursements. Alternative payment methods may include, but are not be limited to, shared savings arrangements, bundled payments and global payments. Alternative payment methodologies may also include Fee-for-service payments, which are settled or reconciled with a bundled or global payment.
Ambulatory Surgical Center. Any distinct entity that operates exclusively to provide surgical services to patients not requiring hospitalization and meets the requirements of the federal Health Care Financing Administration for participation in the Medicare program.
Behavioral Health Expenses. Payments to Providers, including payer paid and Member cost share amounts, for the provision of behavioral health services.
Calendar Year. The period beginning January 1st and ending December 31st.
Center. The Center for Health Information and Analysis established under M.G.L. c. 12C.
Data Specification Manual. The Data Specification Manual contains data submission requirements including, but not limited to, required fields, file layouts, file components, edit specifications, instructions and other technical specifications.
Fee-for-service. A payment mechanism in which all reimbursable health care activity is described and categorized into discrete and separate units of service and each Provider is separately reimbursed for each discrete service rendered to a patient. Fee-for-service payments include Diagnosis-related Groups (DRGs), per diem payments, fixed procedure code-based fee schedule (including Ambulatory Payment Classification (APC)), and discounted charges-based payments.
Freestanding. Existing independently or physically separated from another health care facility and administered by separate staff with separate records.
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, behavioral health, substance use disorder, mental health, 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 957 CMR 2.04.
Hospital. Any hospital licensed by the Department of Public Health in accordance with the provisions of M.G.L. c. 111, § 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, or any public health care facility.
Incurred but Not Reported (IBNR). Health Care Payer liabilities for claims or non-claims that, as of the date of data extraction, are anticipated but have not been reported to the Payer, have been reported but not yet adjudicated, have been adjudicated but not fully paid, or are in dispute.
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 Due to Financial Performance. Includes adjustments to a contracted payment amount, or additions to a base payment amount, or any other payments that are based solely on the achievement of financial or cost-based measures.
Payments Due to Quality Performance. Includes adjustments to a contracted payment amount, or additions to a base payment amount, or any other payments that are based on the achievement of quality measures (e.g., quality, access, and/or patient experience).
Per Member per Month (PMPM). An adjustment made by dividing an annual amount by Member Months.
Pharmacy Benefit Manager (PBM). A Third Party Administrator of prescription drug coverage programs. A PBM includes an entity that provides any of the following services on behalf of Payers or self-insured employer plans: pharmacy claims processing, pharmacy network contracting, drug formulary management, or manufacturer drug rebate contracting.
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 patient care services.
Prescription Drug Rebates. Any rebates, discounts, and other price concessions (including concessions from price protection and hold harmless contract clauses) provided by pharmaceutical manufacturers for prescription drugs with specified dates of fill, excluding manufacturer-provided fair market value bona fide service fees.
Primary Care Expenses. Payments to Providers, including payer paid and Member cost share amounts, for the provision of primary care services.
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 also include any carrier or Third Party Administrator that contracts with the office of Medicaid, the Massachusetts Health 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 ConnectorCare Health Insurance program, Medicaid managed care organizations, Medicare Advantage Plans, 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.
Provider Organization. Any corporation, partnership, business trust, association or organized group of persons, which is in the business of health care delivery or management, whether incorporated or not that represents one or more Providers in contracting with carriers for the payments of Heath Care Services including, but not limited to, physician organizations, physician-hospital organizations, independent practice associations, provider networks, accountable care organizations and any other organization that contracts with carriers for payment for 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.
Registered Provider Organization. A Provider Organization that has been registered in accordance with M.G.L. c. 6D, § 11.
Relative Prices. The contractually negotiated amounts paid to Massachusetts Providers by each 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 957 CMR 2.05.
Surcharge Payer. An individual or entity, including a managed care organization, that pays for or arranges for the purchase of Health Care Services provided by Hospitals and Ambulatory Surgical Center services provided by Ambulatory Surgical Centers; provided however, that the term "Surcharge Payer" shall not include:
(a) Title XVIII and Title XIX programs and their beneficiaries or recipients;
(b) other governmental programs of public assistance and their beneficiaries or recipients; and
(c) the workers' compensation program established pursuant to M.G.L. c. 152.
Third Party Administrator. An entity who, on behalf of a Payer 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 include any entity with claims data, eligibility data, provider files, and other information relating to health care provided to residents of the Commonwealth and Health Care Services 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.
