957 CMR 11.02 - Definitions

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.

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.

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.

Notes

957 CMR 11.02

Adopted by Mass Register Issue 1334, eff. 3/10/2017.