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 8.03 - Data Reporting Requirements

(a) APCD Health Care Claims and Associated Data. Payers shall provide data relating to Medical Claims, Pharmacy Claims, Dental Claims, Member Eligibility Files, Provider Files, Benefit Plan and Product Files. Payers must provide claims-line detail for all health care services provided to Massachusetts residents, whether or not the health care was provided within Massachusetts, including out-of-state residents of a Massachusetts-based employer or Massachusetts employment site, and out-of-state residents of a Massachusetts licensed health care payer. Such data shall include but is not limited to fully-insured and self-funded accounts, to the extent allowable under federal law governing health care provided by employers to employees, and all commercial medical products for all individuals and all group sizes.

(b) CHIA will issue Data Submission Guides and associated Administrative Bulletins to delineate the reporting structure and requirements for this data.

(c) A Self-funded Employee Plan or third-party administrator or carrier providing claims administration services to a Self-funded Employee Plan, shall not be required to submit data pursuant to 957 CMR 8.03, provided, however, that such data may be submitted on a voluntary basis in accordance with the Data Submission Guides and associated Administrative Bulletins referenced in 957 CMR 8.03(2)(b).

(a) Inpatient Merged Case Mix and Charge Data. Hospitals shall submit inpatient hospital merged case mix and charge data for all discharges. This data includes, but is not limited to, information about patient demographics, physicians, diagnoses, E-codes, procedures, admission type and source, patient status disposition, payment type and source, accommodation revenue center charges and days, and ancillary revenue center charges. If the patient is admitted after an Emergency Department Visit or outpatient observation stay, the record should be reported as an inpatient discharge with the appropriate ED and observation identifiers. Upon admission, observation services should be reported as inpatient observation services and included with the inpatient discharge record.

(b) Outpatient Observation Data. Hospitals shall submit Outpatient Observation Data for all observation stays. An outpatient observation stay is reported for each patient that receives Observation Services and is not admitted. An example of an outpatient observation stay might be a post-surgical day care patient that, after a normal recovery period, continues to require hospital observation and is then released from the hospital. The Outpatient Observation Data includes, but is not limited to, information about patient demographics, physicians, diagnoses, procedures, observation type and source, patient's departure status, payment source and charges. If the patient received Observation Services but is not admitted following an Emergency Department visit, the visit should be reported as an outpatient observation stay with an appropriate ED identifier.

(c) Outpatient Emergency Department Visit Data. Hospitals shall submit Outpatient Emergency Department Visit data for all Emergency Department Visits, including Satellite Emergency Facility visits, by patients whose visits result in neither an outpatient observation stay nor an inpatient admission at the reporting facility. This data includes, but is not limited to, information about patient demographics, physicians, diagnoses, services, visit source and disposition, payment source, charges, mode of transport, and E-codes.