All defined terms in 957 CMR 11.00 are capitalized. As used in
957 CMR 11.00 and the
Data Submission Manual, unless the
context requires otherwise, the following terms shall have the following
meanings:
Acute Hospital
. The teaching hospital
of the University of Massachusetts Medical School and any hospital licensed
under M.G.L. c. 111, § 51 and which contains a majority of
medical-surgical, pediatric, obstetric, and maternity beds, as defined by the
Department of Public Health.
Adjudicatory Proceeding
. A proceeding
before an agency in which the legal rights, duties or privileges of
specifically named persons or entities are required by constitutional right or
by any provision of the General Laws to be determined after an opportunity for
an agency hearing.
Advanced Care Settings
. Sites at which
more complex care can be provided for one or more clinical services.
Audited Financial Statements
. A
complete set of financial statements of an Entity, including the notes to the
financial statements, which are subject to an independent audit in accordance
with
Generally Accepted Auditing Standards (GAAS). The
independent auditor issues an opinion as to whether or not the accompanying
financial statements are presented fairly in accordance with Generally
Accepted Accounting Principles (GAAP).
Behavioral Health Services
. Supplies,
care, and services for the diagnosis, treatment, or management of patients with
mental health or substance use disorders.
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; provided that, unless otherwise noted,
Carrier
shall not include any Entity to the extent it
offers a policy, certificate or contract that provides coverage solely for
dental care services or vision care services.
Center
. The Center for Health
Information and Analysis established in M.G.L. c. 12C.
Clinical Affiliation
. Any relationship
between a Provider or Provider Organization and another Entity for the purpose
of increasing the level of collaboration in the provision of Health Care
Services, including, but not limited to, sharing of physician resources in
hospital or other ambulatory settings, co-branding, expedited transfers to
Advanced Care Settings, provision of inpatient consultation coverage or call
coverage, enhanced electronic access and communication, co-located services,
provision of capital for service site development, Joint Training Programs,
video technology to increase access to expert resources and sharing of
hospitalists or intensivists.
Commission
. The Health Policy
Commission established in M.G.L. c. 6D.
Community Advisory Board
. Committees,
boards, or other oversight and governance bodies engaging the community of a
Provider Organization, including, but not limited to patient and family
advisory councils, as defined in 105 CMR 130.1801: Policies and
Procedures for Patient and Family Advisory Council, or community
benefits advisory boards.
Consolidating Schedule
. A document
that accompanies the consolidated Audited Financial Statements, which includes
detailed financial statements of subsidiary hospital(s) and the other
organizations that comprise the consolidated entity.
Contracting Affiliation
. Any
relationship between a Provider Organization and another Provider or Provider
Organization for the purposes of negotiating, representing, or otherwise acting
to establish contracts for the payment of Health Care Services, including for
payment rates, incentives, and operating terms, with a Payer or Third-party
Administrator.
Corporate Affiliation
. Any
relationship between two Entities that reflects, directly or indirectly, a
partial or complete controlling interest or partial or complete common
control.
Data Submission
Manual. A manual published by the MA-RPO Program as an
administrative bulletin, containing specifications, submission guidelines, and
timelines for Registration and data collection.
Division
. The Massachusetts Division
of Insurance established in M.G.L. c. 26, § 1.
Entity
. A corporation, sole
proprietorship, partnership, limited liability company, trust, foundation, or
any other organization formed for the purpose of carrying on a commercial or
charitable enterprise.
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.
Fiscal Year
. The 12-month period
during which a Provider Organization keeps its accounts and which is identified
by the calendar year in which it ends.
Full-time Equivalent
. The ratio of the
total payroll hours for employees to the standard number of annual full-time
payroll hours, and the equivalent for contracted individuals.
Funds Flow
. The apportionment of
Provider or Provider Organization funds, including payments from Payers and
Third-party Administrators, across affiliated Entities, which shall include
apportionment across hospitals and physicians, across physician groups, across
primary care physicians and specialists, and across employed versus affiliated
physicians.
Governmental Unit
. The Commonwealth,
any board, commission, department, division, or agency of the Commonwealth, and
any political subdivision of the Commonwealth.
Health Care Professional
. A physician
or other health care practitioner licensed, accredited, or certified to perform
specified Health Care Services consistent with law.
Health Care Provider or Provider
. A
provider of Health Care Services or any other person or organization that
furnishes, bills or is paid for Health Care Services delivery in the normal
course of business or any person, corporation, partnership, governmental unit,
state institution or any other entity qualified under the laws of the
Commonwealth to perform or provide Health Care Services.
Health Care Services
. Supplies, care
and services of medical, Behavioral Health, surgical, optometric, dental,
podiatric, chiropractic, 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, home health care provider, and hospice care provider, 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 provided by a health maintenance organization.
Initial Registration
. The first time a
Provider Organization submits an application for Registration, which
application may include one or more parts.
Joint Training Programs
. A training
program, including but not limited to student education and graduate medical
education, jointly sponsored by one or more Providers or Provider
Organizations.
Local Practice Group
. A group of
Health Care Professionals that functions as a subgroup of a Provider
Organization (i.e., groups broken out from the larger Provider
Organization for purposes of data reporting and market comparisons).
Major Service Category
. A set of
service categories as specified in the
Data Submission Manual,
including:
(a) Acute Hospital
inpatient services, by major diagnostic category;
(b) outpatient and ambulatory services, by
categories as defined by the Centers for Medicare and Medicaid Services, or as
specified in the
Data Submission Manual, not to exceed 15,
including a residual category for "all other" outpatient and ambulatory
services that do not fall within a defined category;
(c) Behavioral Health Services;
(d) professional services, by categories as
defined by the Centers for Medicare and Medicaid Services, or as specified in
the
Data Submission Manual; and
(e) sub-acute services, by major service line
or clinical offering, as specified in the
Data Submission
Manual.
Massachusetts Registration of Provider
Organizations Program
or
MA-RPO Program
.
The Commonwealth program, jointly administered by the Commission and the
Center, pursuant to M.G.L. c. 6D, § 11 and § 12 and M.G.L. c.
12C.
Patient Panel
. The total number of
individual patients seen over the course of the most recent complete 36-month
period.
Payer
. Any entity, other than an
individual, that pays providers for the provision of health care services;
provided, that
Payer
shall include both governmental
and private entities; provided further, that
Payer
shall not include excluded ERISA plans.
Practice Site
. Any site at which
members of a Local Practice Group provide care.
Presiding Officer
. The individual(s)
authorized by law or designated by the Center to conduct an Adjudicatory
Proceeding.
Provider Organization or Health System or
System. Any corporation, partnership, business trust, association
or organized group of persons, which is in the business of health care delivery
or management, whether incorporated or not, that represents one or more Health
Care Providers in contracting with Carriers or Third-party Administrators for
the payment of Health Care Services; provided that the definition shall
include, but not be limited to, physician organizations, physician-hospital
organizations, independent practice associations, Provider networks,
accountable care organizations, and any other organization that contracts with
Carriers or Third-party Administrators for payment for Health Care
Services.
Registration
. The process of becoming
a Registered Provider Organization as established by the Commission pursuant to
M.G.L. c. 6D, § 11, including Initial Registration and Registration
Renewal.
Registration Renewal
. The process for
a Registered Provider Organization to renew its Registration every 24
months.
Registered Provider Organization
(RPO)
. A Provider Organization, which includes a Risk-bearing
Provider Organization, that meets the criteria for Registration pursuant to 958
CMR 6.00:
Registration of Provider Organizations and registers
with the Commission.
Risk-bearing Provider Organization
(RBPO)
. An Entity subject to the requirements of the Division
pursuant to M.G.L. c. 176T.
Risk Certificate
. A certificate of
solvency issued by the Division that demonstrates that a Risk-bearing Provider
Organization has satisfied the certification requirements of M.G.L. c. 176T and
211 CMR 155.00: Risk-bearing Provider Organizations.
Third-party Administrator
. An Entity
that administers payments for Health Care Services on behalf of a client in
exchange for an administrative fee.
