Code of Massachusetts Regulations
957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS
Title 957 CMR 8.00 - All Payer Claims Database (apcd) And Case Mix And Charge Data Submission
Section 8.02 - Definitions
All defined terms in 957 CMR 8.00 are capitalized. As used in 957 CMR 8.00, unless the context requires otherwise, the following words shall have the following meanings:
Acute Hospital Case Mix Databases. The CHIA databases housing Case Mix Data and Charge Data, including, but not limited to, the outpatient emergency department database, the inpatient discharge database and the outpatient observation database.
APCD. The All Payer Claims Database.
APCD Data. Information submitted to CHIA by Payers, including, but not limited to, data regarding member eligibility, products, benefit plans, providers, encounters, and medical, pharmacy, or dental claims.
Calendar Year. The 12-month period commencing January 1st and ending December 31st.
Case Mix. The description and categorization of a hospital's patient population according to criteria approved by CHIA including, but not limited to, primary and secondary diagnoses, primary and secondary procedures, illness severity, patient age and source of payment.
Case Mix Data. Case specific, diagnostic discharge data that describe socio-demographic characteristics of the patient, the medical reason for the admission, treatment and services provided to the patient, and the duration and status of the patient's stay in the hospital. Case Mix data includes, but is not limited to, hospital inpatient data, outpatient observation data, and hospital outpatient emergency department data.
Charge Data. The full, undiscounted total and service-specific charges billed by a hospital to the general public.
CHIA. The Center for Health Information and Analysis.
CMS. The federal Centers for Medicare & Medicaid Services.
Data. APCD Data, Case Mix Data or Charge Data as defined in 957 CMR 8.02.
Data Submission Guide. A manual that specifies data submission requirements including, but not limited to, required fields, file layouts, file components, edit specifications, instructions and other technical specifications.
Emergency Department. The department of a hospital, or health care facility off the premises of a hospital that is listed on the license of the hospital and qualifies as a Satellite Emergency Facility under 105 CMR 130.820 through 130.836, that provides emergency services as defined in 105 CMR 130.020: Satellite Unit. For purposes of 957 CMR 8.00, outpatient emergency departments include both the on-campus department of the hospitals that provides emergency services and any satellite emergency facilities on the hospital's license as defined in 105 CMR 130.820: Satellite Emergency Facility (SEF).
Emergency Department Visit. Any visit by a patient to an emergency department that results in registration at the Emergency Department but does not result in an outpatient observation stay nor the inpatient admission of the patient at the reporting facility. An Emergency Department visit occurs even if the only service provided to a registered patient is triage or screening.
Encounter Data. Data relating to the treatment or services rendered by a provider to a patient.
Health Care Claims Data. Information consisting of, or derived directly from, member eligibility information, medical claims, pharmacy claims, dental claims, and other data submitted by health care payers to CHIA.
Health Care Services. Supplies, care and services of a medical, 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 Plan Information. Information submitted to CHIA by Payers, including, but not limited to, aggregate data on membership and financials by insurance products and plan design, administrative expenses, benefit levels, premiums, member utilization and medical expenses, provider price variation and provider payment arrangements.
Hospital. Any hospital licensed by the Department of Public Health in accordance with the provisions of M.G.L. c. Ill, § 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.
Hospital Fiscal Year. The 12-month period during which a hospital keeps its accounts and which ends in the calendar year by which it is identified. For Case Mix submissions this is October 1st through September 30th.
Integrated Care Organization (ICO). A comprehensive network of medical, behavioral-health care, and long-term services and support providers that integrates all components of care, either directly or through subcontracts, and has been designated as an ICO to provide services to dual eligible individuals under M.G.L. c. 118E. ICOs are responsible for providing enrollees with the full continuum of Medicare and MassHealth covered services.
Managed Care Organization. A managed care organization, as defined in 42 CFR 438.2, and any eligible health insurance plan, as defined in M.G.L. c. 118H, § 1, that contracts with MassHealth or the Commonwealth Health Insurance Connector Authority; provided, however, that a managed care organization shall not include a senior care organization, as defined in M.G.L. c. 118E, §9D.
Medical Record Number. The unique number assigned to each patient within a hospital that distinguishes the patient and the patient's hospital record(s) from all others in that institution.
Member. A person who holds an individual contract or a certificate under a group arrangement contracted with a Payer.
Member Eligibility File. A file that includes data about a person who receives health care coverage from a payer, including but not limited to subscriber and member identifiers; member demographics; race, ethnicity and language information; plan type; benefit codes; enrollment start and end dates; and behavioral and mental health, substance abuse and chemical dependency and prescription drug benefit indicators.
Observation Services. Those services furnished on a hospital's premises that are reasonable and necessary to further evaluate the patient's condition and provide treatment to determine the need for possible admission to the hospital. These services include the use of a bed and periodic monitoring by a hospital's physician, nursing and other staff. If the patient is admitted, observation services are reported as inpatient observation services and included in the inpatient discharge record. If the patient is not admitted, observation services are reported as outpatient observation services and included in the outpatient observation stay record.
Payer. A Private Health Care Payer and a Public Health Care Payer.
Private Health Care Payer. A private entity that contracts to provide, deliver, arrange for, pay for, or reimburse any of the costs of Health Care Services. A Private Health Care Payer includes 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, to the extent allowable under federal law governing health care provided by employers to employees, a health maintenance organization licensed under M.G.L. c. 176G, an ICO, an SCO, and third-party administrators.
Public Health Care Payer. The Medicaid program established in M.G.L. c. 118E; any carrier or other entity that contracts with the office of Medicaid or the Commonwealth Health Insurance Connector to pay for or arrange for the purchase of health care services on behalf of individuals enrolled in health coverage programs under Titles XIX or XXI, or under the Connector Care Health Insurance program, including prepaid health plans subject to the provisions of St. 1997, c. 47, § 28; the Group Insurance Commission established under M.G.L. c. 32A; and any city or town with a population of more than 60,000 that has adopted M.G.L. c. 32B.
Quarter. The three-month period including January 1st through March 31st; April 1st through June 30th; July 1st through September 30th; and October 1st through December 31st.
Self-funded Employee Plan. An employer-sponsored health benefit plan, where the employer is liable for the incurred costs of the Health Care Services for its employees and plan members and the administrative service fees. A Self-funded Employee Plan shall not include a governmental plan as defined in Section 414(d), Internal Revenue Code or a non-electing church plan as described in Section 410 (d), Internal Revenue Code.
Senior Care Organization (SCO). A comprehensive network of medical, health care and social service providers that integrates all components of care, either directly or through subcontracts. Senior Care Organizations are responsible for providing enrollees with the full continuum of Medicare and MassHealth covered services.
Website. The website of the Center for
Health Information and Analysis located at
