211 CMR 52.16 - Material to Be Provided to the Office of Patient Protection

Current through Register 1466, April 1, 2022

(1) A Carrier shall provide the following to the Office of Patient Protection at the same time the Carrier provides such material to the Bureau of Managed Care:
(a) A copy of every Evidence of Coverage and amendments thereto offered by the Carrier.
(b) A copy of the Provider directory described in 211 CMR 52.15.
(c) A copy of the materials specified in 211 CMR 52.14.
(2) A Carrier shall provide the following to the Office of Patient Protection by no later than April 1st:
(a) A list of sources of independently published information assessing Insured satisfaction and evaluating the quality of Health Care Services offered by the Carrier.
(b) A report of the percentage of physicians and Nurse Practitioners and Physician Assistants who voluntarily and involuntarily terminated participation contracts with the Carrier during the previous calendar year for which such data has been compiled and the three most common reasons for voluntary and involuntary Provider disenrollment;
1. For the purposes of 211 CMR 52.16(2)(b), Carriers shall exclude physicians, Nurse Practitioners, and Physician Assistants who have moved from one physician and/or Nurse Practitioner or Physician Assistant group to another but are still under contract with the Carrier.
2. For the purposes of 211 CMR 52.16(2)(b) "voluntarily terminated" means that the physician, Nurse Practitioner, or Physician Assistant terminated the contract with the Carrier.
3. For the purposes of 211 CMR 52.16(2)(b) "involuntarily terminated" means that the Carrier terminated its contract with the physician, Nurse Practitioner, or Physician Assistant;
(c) The percentage of premium revenue expended by the Carrier for Health Care Services provided to Insureds for the most recent year for which information is available;
(d) A report detailing, for the previous calendar year, the total number of:
1. filed Grievances, Grievances that were approved internally, Grievances that were denied internally, and Grievances that were withdrawn before resolution; and
2. external appeals pursued after exhausting the internal Grievance process and the resolution of all such external appeals. The report shall identify for each such category, to the extent such information is available, the demographics of such Insureds, which shall include, but need not be limited to, race, gender and age; and
(e) A report detailing for the previous calendar year the total number of:
1. medical or surgical claims submitted to the carrier;
2. medical or surgical claims denied by the carrier;
3. mental health or substance use disorder claims submitted to the carrier;
4. mental health or substance use disorder claims denied by the carrier; and
5. medical or surgical claims and mental health or substance use disorder claims denied by the carrier because:
a. the insured failed to obtain pre-treatment authorization or referral for services;
b. the service was not medically necessary;
c. the service was experimental or investigational;
d. the insured was not covered or eligible for benefits at the time services occurred;
e. the carrier does not cover the service or the provider under the insured's plan;
f. duplicate claims had been submitted;
g. incomplete claims had been submitted;
h. coding errors had occurred; or
i. of any other specified reason.
(f) A Carrier that provides specified services through a workers' compensation preferred provider arrangement shall be deemed to have meet the requirements of 211 CMR 52.16(1)(a) through (c) and (2)(c) through (e).

Notes

211 CMR 52.16
Amended by Mass Register Issue 1345, eff. 8/11/2017.

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