Code of Massachusetts Regulations
957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS
Title 957 CMR 2.00 - Payer Data Reporting
Section 2.06 - Reporting Alternative Payment Methods

1. Payers must report APM data separately by Medicare, Medicaid, commercial full-claim, and commercial partial-claim plans, and any other insurance categories as defined by the Data Specification Manual. Commercial (self- and fully-insured) data for Registered Provider Organizations, Physician Groups, and Physician Local Practice 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 Registered Provider Organizations, or Physician Groups, Physician Local Practice Groups 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.

2. Payers must report APM data separately by product type as defined by the Data Specification Manual.

3. When reporting preliminary APM data, Payers shall include IBNR estimates resulting in approximated completed claims for periods that are not yet considered complete.

4. Payers shall report APM for Physician Groups and Physician Local Practice Groups with at least 36,000 Member Months for the Calendar Year. Payers shall report APM 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 APM 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. Payers shall report APM by zip code for all Massachusetts Members based on the zip code of the Member. The Center shall not publicly report zip code APM data, unless aggregated to an amount appropriate to protect patient confidentiality.

2. Payers shall report APM 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 (self- and fully-insured) 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 APM 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 APM by zip code, Payers shall include IBNR estimates resulting in approximated completed claims for periods that are not yet considered complete.

1. Payers must report APM data separately by Medicare, Medicaid, and 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 Physician Groups, Physician Local Practice groups, or 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 (self- and fully-insured) data for Registered Provider Organizations, Physician Groups, Physician Local Practice 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.

2. Payers shall report hospital categories separately for inpatient and outpatient.

3. Payers must report APM data separately by hospital category for acute hospitals, chronic hospitals, rehabilitation hospitals, and psychiatric hospitals.

4. When reporting preliminary APM data, Payers shall include IBNR estimates resulting in approximated completed claims for periods that are not yet considered complete.

5. Notwithstanding 957 CMR 2.06(3)(a)3., Payers shall report additional behavioral health-only APM data for acute hospitals with psychiatric or substance abuse units with the psychiatric hospital file. Payers must develop a standard definition of behavioral health services to be used for all acute hospitals impacted by 957 CMR 2.06(3).