As used in
211 CMR
52.00, the following words mean:
Accreditation
. A written determination
by the Bureau of Managed Care of compliance with M.G.L. c. 176O,
211 CMR
52.00 and
958 CMR
3.000: Health Insurance Consumer
Protection.
Actively Practices
. A Health Care
Professional who regularly treats or manages patients in a clinical
setting.
Administrative Disenrollment
. A change
in the status of an Insured whereby the Insured remains with the same Carrier
but his or her membership may appear under a different identification number.
Examples of an Administrative Disenrollment are a change in employers, a move
from an individual plan to a spouse's plan, or any similar change that may be
recorded by the Carrier as both a disenrollment and an enrollment.
Adverse Determination
. A
determination, based upon a review of information provided, by a Carrier or its
designated Utilization Review Organization, to deny, reduce, modify, or
terminate an admission, continued inpatient stay, or the availability of any
other Health Care Services, forfailure to meet the requirements for coverage
based on Medical Necessity, appropriateness of health care setting and level of
care, or effectiveness, including a determination that a requested or
recommended Health Care Service or treatment is experimental or
investigational. An
Adverse Determination
includes any
denial of access to an out-of-Network Provider at an in-Network benefit level
where there is an oral or written assertion by an Insured or treating Provider
that a Carrier's preferred Provider Network does not have Providers who are
able and available to treat the patient's specific condition and the preferred
Provider Network is therefore not adequate to deliver the needed benefits at
the preferred Provider level.
Alternative Payment Contract
. Any
contract between a Carrier and a Provider or Provider organization that
utilizes alternative payment methodologies, which are methods of payment that
are not solely based on fee-for-service reimbursements and that may include,
but is not limited to, shared savings arrangements, bundled payments, global
payments, and fee-for-service payments that are settled or reconciled with a
bundled or global payment.
Ambulatory Review
. Utilization Review
of Health Care Services performed or provided in an out patient setting,
including, but not limited to, outpatient or ambulatory surgical, diagnostic
and therapeutic services provided at any medical, surgical, obstetrical,
psychiatric and chemical dependency Facility, as well as other locations such
as laboratories, radiology facilities, Provider offices and patient
homes.
Asynchronous or Asynchronous
Telehealth. An exchange of information regarding a patient that
does not occur in real time, including but not limited to the secure collection
and transmission of a patient's medical information, clinical data clinical
images, laboratory results, or a self-reported medical history.
Behavioral Health Manager
. A company,
organized under the laws of the Commonwealth of Massachusetts or organized
under the laws of another state and qualified to do business in the
Commonwealth, that has entered into a contractual arrangement with a Carrier to
provide or arrange for the provision of behavioral, substance use disorder and
mental Health Services to voluntarily enrolled members of the Carrier.
Behavioral Health Services
. Care and
services for the evaluation, diagnosis, treatment, consultation, prescribing,
monitoring or management of mental health, developmental, or substance use
disorders. Such care and services may be provided by any Health Care
Professional for whom such services are within the scope of licensure for such
Health Care Professional. Behavioral Health Services shall also include but not
be limited to Partial Hospital Programs and Intensive Outpatient
Programs.
Behavioral Health Specialty Care
.
Behavioral Health Services dedicated to treating particular behavioral health
conditions. A behavioral health Provider should be listed as providing specific
Behavioral Health Specialty Care when they regularly provide the care.
Bureau of Managed Care or Bureau. The
bureau in the Division of Insurance established by M.G.L. c. 176O, §
2.
Capitation
. A set payment per patient
per unit of time made by a Carrier to a licensed Health Care Professional,
Health Care Provider group, or organization that employs or utilizes services
of Health Care Professionals to cover a specified set of services and
administrative costs without regard to the actual number of services
provided.
Carrier
. An insurer licensed or
otherwise authorized to transact accident or health insurance under M.G.L. c.
175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a
nonprofit medical service corporation organized under M.G.L. c. 176B; a health
maintenance organization organized under M.G.L. c. 176G; and an organization
entering into a preferred Provider arrangement under M.G.L. c. 176I, but not
including an employer purchasing coverage or acting on behalf of its employees
or the employees of one or more subsidiaries or affiliated corporations of the
employer. Unless otherwise noted, the term "Carrier" shall not include any
entity to the extent it offers a policy, certificate, or contract that is not a
health benefit plan as defined in M.G.L. c. 176J, § 1.
Case Management
. A coordinated set of
activities conducted for individual patient management of serious, complicated,
protracted or other health conditions.
Chronic Disease Management
. Care and
services for the management of chronic conditions, including
(a) conditions, defined by the federal
Centers for Medicare and Medicaid Services that include, but are not limited
to, diabetes, chronic obstructive pulmonary disease, asthma, congestive heart
failure, hypertension, history of stroke, cancer, and coronary artery
disease;
(b) congenital anomalies
and hereditary conditions; and
(c)
other chronic conditions that last one year or more and require ongoing medical
attention or limit activities of daily living or both.
Clean and Complete Credentialing
Application
. A credentialing application which is appropriately
signed and dated by the Provider, and which includes all of the applicable
information requested from the Provider by the Carrier.
Clinical Peer Reviewer
. A physician or
other Health Care Professional, other than the physician or other Health Care
Professional who made the initial decision, who holds a nonrestricted license
from the appropriate professional licensing board in Massachusetts, current
board certification from a Specialty board approved by the American Board of
Medical Specialties or of the Advisory Board of Osteopathic Specialists from
the major areas of clinical services or, for non-physician Health Care
Professionals, the recognized professional board for their Specialty, who
Actively Practices in the Same or Similar Specialty as typically manages the
medical condition, procedure or treatment under review, and whose compensation
does not directly or indirectly depend upon the quantity, type or cost of the
services that such person approves ordenies.
Clinical Review Criteria
. The written
screening procedures, decisions, abstracts, clinical protocols and practice
guidelines used by a Carrier to determine the Medical Necessity and
appropriateness of Health Care Services.
Commissioner
. The Commissioner of
Insurance, appointed pursuant to M.G.L. c. 26, § 6, or his or her
designee.
Complaint.
(a) any Inquiry made by or on behalf of an
Insured to a Carrier or Utilization Review Organization that is not explained
or resolved to the Insured's satisfaction within three business Days of the
Inquiry;
(b) any matter concerning
an Adverse Determination; or
(c) in
the case of a
Carrier or Utilization Review Organization that does not have an
internal Inquiry process, a Complaint means any Inquiry.
Concurrent Review
. Utilization Review
conducted during an Insured's inpatient hospital stay or course of
treatment.
Cost Sharing
or
Cost-sharing
. Includes deductibles, coinsurance,
copayments, or similar charges required of an Insured, but does not include
premiums, balance-billing amounts for out-of-Network Providers, or spending for
non-covered Benefits.
Covered Benefits
or
Benefits
. Health Care Services to which an Insured is
entitled under the terms of the Health Benefit Plan.
Days
. Calendar days, unless otherwise
specified in
211 CMR
52.00; provided, that computation of days specified in
211 CMR
52.00 begins with the first day following the
referenced action, and provided further that if the final day of a period
specified in
211 CMR
52.00 falls on a Saturday, Sunday or state holiday,
the final day of the period will be deemed to occur on the next working
day.
Dental Benefit Plan
. A policy,
contract, certificate or agreement of insurance entered into, offered or issued
by a Dental Carrier to provide, deliver, arrange for, pay for, or reimburse any
of the costs solely for Dental Care Services.
Dental Care Professional
. A dentist or
other dental care practitioner licensed, accredited or certified to perform
specified Dental Services consistent with the law.
Dental Care Provider
. A Dental Care
Professional or Facility licensed to provide Dental Care Services.
Dental Care Services
or
Dental Services
. Services for the diagnosis,
prevention, treatment, cure or relief of a dental condition, illness, injury or
disease.
Dental Carrier
. An entity that offers
a policy, certificate or contract that provides coverage solely for Dental Care
Services and is: an insurer licensed or otherwise authorized to transact health
insurance under M.G.L. c. 175; a nonprofit hospital service corporation
organized under M. G.L. c. 176A; a nonprofit medical service corporation
organized under M.G.L. c. 176B; a dental service corporation organized under
M.G.L. c. 176E, or an organization entering into a preferred Provider
arrangement under M.G.L. c. 176I, but not including an employer purchasing
coverage or acting on behalf of its employees or the employees or one or more
subsidiaries or affiliated corporations of the employer, that offers a policy,
certificate or contract that provides coverage solely for Dental Care
Services.
Discharge Planning
. The formal process
for determining, prior to discharge from a Facility, the coordination and
management of the care that an Insured receives following discharge from a
Facility.
Division
. The Division of Insurance
established pursuant to M.G.L. c. 26, § 1.
Emergency Medical Condition
. A medical
condition, whether physical, behavioral, related to substance use disorder, or
mental, manifesting itself by symptoms of sufficient severity, including severe
pain, that the absence of prompt medical attention could reasonably be expected
by a prudent layperson who possesses an average knowledge of health and
medicine, to result in placing the health of an Insured or another person in
serious jeopardy, serious impairment to body function, or serious dysfunction
of any body organ or part, or, with respect to a pregnant woman, as further
defined in § 1867(e)(l)(B) of the Social Security Act,
42 U.S.C.§
1395dd(e)(1)(B).
Evidence of Coverage
. Any certificate,
contract or agreement of health insurance including riders, amendments,
endorsements and any other supplementary inserts or a summary plan description
pursuant to § 104(b)(1) of the Employee Retirement Income Security Act of
1974, 29 U.S.C. §
1024(b), issued to an
Insured specifying the Benefits to which the Insured is entitled. For workers'
compensation preferred Provider arrangements, the Evidence of Coverage will be
considered to be the information annually distributed pursuant to
211
CMR 51.04(3)(i)1. through
3.
Facility
. A licensed institution
providing Health Care Services or a health care setting including, but not
limited to, hospitals and other licensed inpatient centers, ambulatory surgical
or treatment centers, skilled nursing centers, residential treatment centers,
diagnostic, laboratory and imaging centers, and rehabilitation and other
therapeutic health settings.
Finding of Neglect
. A written
determination by the Commissioner that a Carrier has failed to make and file
the materials required by M.G.L. c. 176O or
211 CMR
52.00 in the form and within the time required.
Grievance
. Any oral or written
Complaint submitted to the Carrier that has been initiated by an Insured, or on
behalf of an Insured with the consent of the Insured, concerning any aspect or
action of the Carrier relative to the Insured including, but not limited to,
review of Adverse Determinations regarding scope of coverage, denial of
services, rescission of coverage, quality of care and administrative
operations, in accordance with the requirements of M.G.L. c. 176O and
958 CMR
3.000: Health Insurance Consumer
Protection.
Health Benefit Plan
. A policy,
contract, certificate or agreement of insurance entered into, offered or issued
by a Carrier to provide, deliver, arrange for, pay for, or reimburse any of the
costs of Health Care Services. Unless otherwise noted,
Health
Benefit Plan
shall not include any policy, certificate, or
contract that is not a health benefit plan as defined in M.G.L. c. 176J, §
1.
Health Care Professional
. A physician
or other health care practitioner licensed, accredited or certified to perform
specified Health Services consistent with the law.
Health Care Provider
or
Provider
. A Health Care Professional or
Facility.
Health Care Services
or
Health Services
. Services for the evaluation,
consultation, prescribing, diagnosis, prevention, treatment, management, cure
or relief of a physical, behavioral, substance use disorder or mental health
condition, illness, injury or disease.
HMO
. A health maintenance organization
licensed pursuant to M.G.L. c. 176G.
Incentive Plan
. Any compensation
arrangement between a Carrier and Health Care Professional or Licensed Health
Care Provider Group or organization that employs or utilizes services of one or
more licensed Health Care Professionals that may directly or indirectly have
the effect of reducing or limiting specific services furnished to Insureds of
the organization.
Incentive Plan
shall not mean
contracts that involve general payments such as Capitation payments or shared
risk agreements that are made with respect to Health Care Professionals or
Providers, or Health Care Professional groups or Provider groups which are made
with respect to groups of Insureds if such contracts, which impose risk on such
Health Care Professionals or Providers or Health Care Professional groups or
Provider groups for the cost of medical care, services and equipment provided
or authorized by another Health Care Professional or Provider or by another
Health Care Professional group or Provider group, comply with
211 CMR
52.00.
Inquiry
. Any communication by or on
behalf of an Insured to the Carrier or Utilization Review Organization that has
not been the subject of an Adverse Determination and that requests redress of
an action, omission or policy of the Carrier.
Insured
. An enrollee, covered person,
Insured, member, policy holder or subscriber of a Carrier, including a Dental
or Vision Carrier, including an individual whose eligibility as an Insured of a
Carrier is in dispute or under review, or any other individual whose care may
be subject to review by a Utilization Review program or entity as described
under the provisions of M.G.L. c. 176O,
211 CMR
52.00 and
958 CMR
3.000: Health Insurance Consumer
Protection.
Internet Website
. Includes, but shall
not be limited to, an internet website, an intranet website, a web portal, or
electronic mail.
JCAHO
. The Joint Commission on
Accreditation of Health Care Organizations.
Licensed Health Care Provider Group. A
partnership, association, corporation, individual practice association, or
other group that distributes income from the practice among members. An
individual practice association is a Licensed Health Care Provider Group only
if it is composed of individual Health Care Professionals and has no
subcontracts with Licensed Health Care Provider Groups.
Limited Health Services
.
Pharmaceutical services, and such other services as may be determined by the
Commissioner to be Limited Health Services. Limited Health
Services
shall not include hospital, medical, surgical or
emergency services, except as such services are provided in conjunction with
the Limited Health Services set forth in the preceding sentence.
Limited Network Plan
. A Limited
Network plan as defined in
211 CMR
152.00: Health Benefit Plans Using Limited,
Regional or Tiered Provider Networks.
Managed Care Organization
or
MCO
. A Carrier subject to M.G.L. c. 176O.
Material Change
. A modification to any
of a Carrier's, including a Dental or Vision Carrier's, procedures or documents
required by
211 CMR
52.00 that substantially affects the rights or
responsibilities of:
(a) an
Insured;
(b) a Carrier, including a
Dental or Vision Carrier; and/or
(c) a Health, Dental, or Vision Care
Provider.
Medical Necessity
or
Medically Necessary
. Health Care Services that are
consistent with generally accepted principles of professional medical practice
as determined by whether:
(a) the
service is the most appropriate available supply or level of service for the
Insured in question considering potential benefits and harms to the
individual;
(b) is known to be
effective, based on scientific evidence, professional standards and expert
opinion, in improving health outcomes; or
(c) for services and interventions not in
widespread use, is based on scientific evidence.
National Accreditation Organization.
JCAHO, NCQA, URAC or any other national Accreditation entity approved by the
Division that accredits Carriers that are subject to the provisions of M.G.L.
c. 176O and
211 CMR
52.00.
NCQA
. The National Committee for
Quality Assurance.
NCQA Standards. The Standards and
Guidelines for the Accreditation of Health Plans published annually by the
NCQA.
Network
or
Provider
Network. A group of health, Dental or Vision Care Providers who
contract with a Carrier, including a Dental or Vision Carrier, or affiliate to
provide health, Dental or Vision Care Services to Insureds covered by any or
all of the Carrier's, including a Dental or Vision Carrier's or affiliate's,
plans, policies, contracts or other arrangements. Network shall not mean those
Participating Providers who provide services to subscribers of a nonprofit
hospital service corporation organized under M.G.L. c. 176A, or a nonprofit
medical service corporation organized under M.G.L. c. 176B.
Nongatekeeper Preferred Provider Plan.
An insured preferred Provider plan approved for offer under M.G.L. c. 176I
which offers preferred Benefits when a covered person receives care from
preferred Network Providers but does not require the Insured to designate a
Primary Care Provider to coordinate the delivery of care or receive referrals
from the Carrier or any Network Provider as a condition of receiving Benefits
at the preferred benefit level.
Nurse Practitioner
. A registered nurse
who holds authorization in advanced nursing practice as a nurse practitioner
under M.G.L. c. 112, § 80B.
Office of Patient Protection
. The
office within the Health Policy Commission established by M.G.L. c. 6D, §
16, responsible for the administration and enforcement of M.G.L. c. 176O,
§§ 13, 14, 15 and 16.
Participating Provider
. A Provider
who, under a contract with the Carrier, including a Dental or Vision Carrier,
or with its contractor or subcontractor, has agreed to provide health, Dental
or Vision Care Services to Insureds with an expectation of receiving payment,
other than coinsurance, copayments or deductibles, directly or indirectly from
the Carrier, including a Dental or Vision Carrier.
Physician Assistant
. A person who is a
graduate of an approved program for the training of physician assistants who is
supervised by a registered physician in accordance with M.G.L. c. 112, §
9C through 9H and who has passed the Physician Assistant National Certifying
Exam or its equivalent.
Preventive Health Services
. Any
periodic, routine, screening or other services designed for the prevention and
early detection of illness that a Carrier is required to provide pursuant to
Massachusetts or federal law.
Primary Care Provider
. A Health Care
Professional qualified to provide general medical care for common health care
problems, who supervises, coordinates, prescribes, or otherwise provides or
proposes Health Care Services; initiates referrals for Specialty Care; and
maintains continuity of care within the scope of his or her practice. A Primary
Care Provider may include but not be limited to medical doctors and Nurse
Practitioners and Physician Assistants who concentrate in primary care,
pediatric primary care, and/or gynecological and reproductive health.
Primary Care Services
. Services
delivered by a Primary Care Provider.
Prospective Review
. Utilization Review
conducted prior to an admission or a course of treatment.
Prospective Review
shall include any pre-authorization
and pre-certification requirements of a Carrier or Utilization Review
Organization.
Regional Network Plan. A Regional
Network Plan as defined in
211 CMR
152.00: Health Benefit Plans Using Limited,
Regional or Tiered Provider Networks.
Religious Non-medical Provider
. A
Provider who provides no medical care but who provides only religious
non-medical treatment or religious non-medical nursing care.
Retrospective Review
. Utilization
Review of Medical Necessity that is conducted after services have been provided
to a patient.
Retrospective Review
shall not include
the review of a claim that is limited to an evaluation of reimbursement levels,
veracity of documentation, accuracy of coding or adjudication for
payment.
Same
or
Similar
Specialty
. The Health Care Professional has similar credentials
and licensure as those who typically provide the treatment in question and has
experience treating the same condition that is the subject of the Grievance.
Such experience shall extend to the treatment of children in a Grievance
involving a child where the age of the patient is relevant to the determination
of whether a requested service or supply is Medically Necessary.
Second Opinion
. An opportunity or
requirement to obtain a clinical evaluation by a Health Care Professional other
than the Health Care Professional who made the original recommendation for a
proposed Health Service, to assess the clinical necessity and appropriateness
of the initial proposed Health Service.
Service Area
. The geographical area as
approved by the Commissioner within which the Carrier, including a Dental or
Vision Carrier, has developed a Network of Providers to afford adequate access
to members for covered Health, Dental or Vision Services.
Site of Service Plan
. An insured
Health Benefit Plan where access to certain specified Network Providers or
access to care in certain specified settings may only be available when the
Carrier determines that it is medically necessary to receive covered care from
these certain Providers or the certain settings. The Utilization Review
processes and Medical Necessity criteria used are required to meet the relevant
requirements of
211 CMR
52.00 and any requirements as determined by the
Commissioner. Whenever a request for services provided by certain specified
Network Providers for care at certain specified locations is denied, Carriers
with Site of Service Plans are to follow all required protocols for Adverse
Determination notices and appeals as required under
211 CMR
52.00.
Specialty or Specialty Care. Health
Care services dedicated to a specific branch of medicine or all Health Care
services not considered primary care. Patients can be referred to a specialist
by a Primary Care Provider for disease-specific care that requires expert
support.
Telehealth
. The use of synchronous or
asynchronous audio, video, electronic media or other telecommunications
technology including, but not limited to:
(i) interactive audio-video
technology;
(ii) remote patient
monitoring devices;
(iii)
audio-only telephone; and
(iv)
online adaptive interviews, for the purpose of evaluating, diagnosing,
consulting, prescribing, treating, managing, or monitoring of a patient's
physical health, oral health, mental health or substance use disorder
condition.
Terminally Ill
or
Terminal
Illness
. An illness that is likely, within a reasonable degree of
medical certainty, to cause one's death within six months, or as otherwise
defined in section 1861(dd)(3)(A) of the Social Security Act,
42 U.S.C. §
1395x(dd)(3)(A).
Tiered Network Plan. A Tiered Network
Plan as described in
211 CMR
152.00: Health Benefit Plans Using Limited,
Regional or Tiered Provider Networks.
URAC
. The American Accreditation
Health Care Commission/URAC, formerly known as the Utilization Review
Accreditation Commission.
Utilization Review
. Set of formal
techniques designed to monitor the use of, or evaluate the clinical necessity,
appropriateness, efficacy, or efficiency of, Health Care Services, procedures
or settings. Such techniques may include, but are not limited to, Ambulatory
Review, Prospective Review, Second Opinion, certification, Concurrent Review,
Case Management, Discharge Planning or Retrospective Review.
Utilization Review Organization. An
entity that conducts Utilization Review under contract with or on behalf of a
Carrier, but does not include a Carrier performing Utilization Review for its
own Health Benefit Plans. A Behavioral Health Manager is considered a
Utilization Review Organization.
Vision Benefit Plan
. A policy,
contract, certificate or agreement of insurance entered into, offered or issued
by a Carrier to provide, deliver, arrange for, pay for, or reimburse any of the
costs solely for Vision Care Services.
Vision Care Professional
. An
ophthalmologist, optometrist or other practitioner licensed, accredited or
certified to perform specified Vision Services consistent with the law.
Vision Care Provider
. A Vision Care
Professional; or a Facility licensed to perform and provide Vision Care
Services.
Vision Care Services
or
Vision Services
. Services for the diagnosis,
prevention, treatment, cure or relief of a vision condition, illness, injury or
disease.
Vision Carrier
. An entity that offers
a policy, certificate or contract that provides coverage solely for Vision Care
Services and is: an insurer licensed or otherwise authorized to transact
accident or health insurance under M.G.L. c. 175; an optometric service
corporation organized under M.G.L. c. 176F, or an organization entering into a
preferred Provider arrangement under M.G.L. c. 176I, but not including an
employer purchasing coverage or acting on behalf of its employees or the
employees of one or more subsidiaries or affiliated corporations of the
employer, that offers a policy, certificate or contract that provides coverage
solely for Vision Care Services.
Visit
. A scheduled, urgent, or
emergency encounter between a covered patient and a Health Care Professional,
whether conducted within the Health Care Professional's office, another
physical location or conducted via synchronous or Asynchronous Telehealth, to
evaluate, diagnose, consult, treat, conduct clinical trials, prescribe, manage
or monitor a covered medical, oral health or behavioral health condition.
Within a Visit, the Health Care Professional will review patient history,
examine the patient's condition, and exercise medical judgment in treating a
patient. In the case of Telehealth Visits, a Health Care Professional must
receive consent from a patient that the encounter will constitute a Visit and
may be subject to Health Benefit Plan Cost-sharing if the Health Care
Professional ever seeks reimbursement for the Telehealth encounter from either
the patient or the patient's Carrier.
