Code of Massachusetts Regulations
957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS
Title 957 CMR 2.00 - Payer Data Reporting
Section 2.04 - Reporting Health Status Adjusted Total Medical Expenses

1. Payers shall report TME by Physician Group and Physician Local Practice Group for Massachusetts Members, separated into the following categories:

2. Payers shall report TME for Physician Groups and Physician Local Practice Groups with at least 36,000 Member Months for the Calendar Year.

3. Payers shall report TME separately for Medicaid, Medicare, commercial full-claim, and commercial partial-claim plans, and any other insurance categories as defined in the Data Specification Manual. Commercial (self- and fully-insured) data for Physicians' Groups for which the Payer is able to collect information on all direct medical claims and subcarrier claims shall be reported in the full-claim category. Commercial (self- and fully-insured) data for Physicians' Groups or zip codes that do not include all medical and subcarrier claims shall be reported in the partial-claim category. Payers must include the full amount paid for medical claims, including amounts paid under stop-loss or reinsurance agreements, even if the Payer was not directly providing payment for those services. Payers shall not include data for which they are the secondary or tertiary payer such as Medicare Supplement.

4. Payers shall report TME data in the aggregate for all Physician Groups and Physician Local Practice Groups with fewer than 36,000 Member Months for the Calendar Year.

5. Payers shall attribute Non-claims Related Payments to a Provider at the Local Practice Group Level and thereafter at the Physician Group Level. If direct attribution is not possible, Payers shall allocate Non-claims Related Payments by Member Months.

6. Payers must report the risk adjustment tool and version used to report the Health Status Adjustment Score. The Center may specify additional requirements for reporting the Health Status Adjustment Score by Administrative Bulletin or in the Data Specification Manual.

7. When reporting preliminary TME by Physician Group and Physician Local Practice Group, Payers shall include IBNR estimates resulting in approximated completed claims for periods that are not yet considered complete.

1. Center for Health Information and Analysis (CHIA) Organization ID or Payer's Internal Provider Number;

2. Insurance Category;

3. Physician Group Name;

4. Physician Local Practice Group Name;

5. Product Type;

6. PCP Member Attribution Designation;

7. Pediatric Indicator;

8. Member Months (annual);

9. Health Status Adjustment Score;

10. Normalized Health Status Adjustment Score: the Health Status Adjustment Score divided by the Payer's average health status adjustment score;

11. Total Medical Claims (annual): the medical claims expenses by the following subcategories: hospital inpatient, hospital outpatient, professional physician, other professional, pharmacy, and any other categories as defined in the Data Specification Manual;

12. Total Non-claims Payments (annual): the Non-claims Related Payments by the following subcategories: incentive programs, risk settlements, care management expenses, and any other categories as defined in the Data Specification Manual; and

13. The Center will delineate any other required data elements in the Data Specification Manual.

1. Payers shall report TME by zip code for all Massachusetts Members based on the zip code of the Member. The Center shall not publicly report zip code TME data, unless aggregated to an amount appropriate to protect patient confidentiality.

2. Payers shall report TME separately for Medicaid, Medicare, commercial full-claim, and commercial partial-claim plans, and any other insurance categories as defined in the Data Specification Manual. Commercial (self- and fully-insured) data for zip codes for which the Payer is able to collect information on all direct medical claims and subcarrier claims shall be reported in the full-claim category. Commercial data for zip codes that do not include all medical and subcarrier claims shall be reported in the partial-claim category. Payers must include the full amount paid for medical claims, including amounts paid under stop-loss or reinsurance agreements, even if the Payer was not directly providing payment for those services. Payers shall not include data for which they are the secondary or tertiary payer such as Medicare Supplement.

3. Payers must report TME data separately by product type as defined by the Data Specification Manual.

4. Payers shall allocate Non-claims Related Payments by Member Months.

5. Payers must report the risk adjustment tool and version used to report the Health Status Adjustment Score. The Center may specify additional requirements for reporting the Health Status Adjustment Score by Administrative Bulletin or in the Data Specification Manual;

6. When reporting preliminary TME by zip code, Payers shall include IBNR estimates resulting in approximated completed claims for periods that are not yet considered complete.

1. Member Zip Code;

2. Product Type;

3. Member Months (annual);

4. Health Status Adjustment Score;

5. Normalized Health Status Adjustment Score: the Health Status Adjustment Score divided by the Payer's average health status adjustment score;

6. Total Medical Claims (annual): the sum of medical claims expenses designated into the following subcategories: hospital inpatient, hospital outpatient, professional physician, other professional, pharmacy, and any other categories as defined in the Data Specification Manual;

7. Total Non-claims Payments (annual): the sum of all Non-claims Related Payments; and

8. The Center will delineate any other required data elements in the Data Specification Manual.