Code of Massachusetts Regulations
957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS
Title 957 CMR 2.00 - Payer Data Reporting
Section 2.08 - Reporting Primary Care and Behavioral Health Expenses
Universal Citation: 957 MA Code of Regs 957.2
Current through Register 1531, September 27, 2024
(1) Primary Care and Behavioral Health Expenses Reporting by Physician Group.
(a)
Reporting Requirements.
1. Payers shall report Primary Care
and Behavioral Health Expenses and Member Months information by
Physician Group for Massachusetts Members, separated into the
following categories:
a. Members
required to select a primary care physician;
b. Members attributed to a primary
care provider pursuant to a contract between the Payer and Provider
for financial or quality performance;
c. All other Members who have been,
"to the maximum extent possible", attributed to a primary care
provider pursuant to M.G.L. c. 176J, § 16; and
d. Members not attributable to a
primary care provider.
2. Payers shall report Primary Care
and Behavioral Health Expenses for Physician Groups with at least
36,000 Member Months for the Calendar Year.
3. Payers must report 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 Physician 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 Physician 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.
4. Payers
shall report Primary Care and Behavioral Health Expenses data in the
aggregate for all Physician Groups with fewer than 36,000 Member
Months for the Calendar Year.
5. When reporting preliminary data,
Payers shall include IBNR estimates resulting in approximated
completed claims for periods that are not yet considered
complete.
(b)
Required Data Elements. The Center will
delineate required data elements and qualitative response questions
in the Data Specification Manual. For purposes of
957 CMR 2.08, primary care and behavioral health services are defined
by standardized coding logic set forth in the Data
Specification Manual.
(2) Due Dates: Annual Reports. Each year, Payers must submit:
(a) preliminary data for the prior
Calendar Year; and
(b)
final data for the Calendar Year for which the payer submitted
preliminary data during the previous reporting cycle. Payers shall
allow for a claims run-out period of at least 90 days after December
31st of the previous Calendar Year. Final
data should reflect at least 15 months of claims run-out. Specific
deadlines will be established in the Data Specification
Manual.
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