Common Summary of Payments Format; Issued 4/21/2017

[LOGO] COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation DIVISION OF INSURANCE 1000 Washington Street, Suite 810 • Boston, MA 02118-6200 (617) 521-7794 • Toll-free (877) 563-4467 http://www.mass.gov/doi CHARLES D. BAKER GOVERNOR KARYN E. POLITO LIEUTENANT GOVERNOR JAY ASH SECRETARY OF HOUSING AND ECONOMIC DEVELOPMENT JOHN C. CHAPMAN UNDERSECRETARY OF CONSUMER AFFAIRS AND BUSINESS REGULATION GARY D. ANDERSON ACTING COMMISSIONER OF INSURANCE # BULLETIN 2017-02 TO: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations FROM: Gary D. Anderson, Acting Commissioner of Insurance DATE: April 21, 2017 RE: Common Summary of Payments Format The Division of Insurance (“Division”) is issuing this Bulletin regarding Massachusetts General Laws Chapter (“Chapter”) 176O, §27, which requires the Division to develop a common summary of payments form for use by Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations (hereinafter referred to as “Carriers”). # Standards for Common Summary of Payments Forms The Division hereby notifies Carriers that a Summary of Payments (“SOP”) must be issued to insureds and must meet the following requirements: - Be easily readable and understandable; - Include all of the elements listed in Exhibit A of this Bulletin; - May be issued via paper or electronic means and shall be delivered in accordance with the requirements set forth below; and - Is issued at the member level to the patient rather than to the subscriber. Carriers shall not specify or describe sensitive health care services in a SOP. The Division will define sensitive health care services through subsequent guidance. In determining the definition, the Division will consider the recommendations of the National Committee on Vital and Health Statistics and similar regulations in other states, and shall consult with experts in fields including, but not limited to, infectious disease, reproductive and sexual health, domestic violence and sexual assault, and mental health and substance use disorders. In the event that the insured member has no liability for payment for any procedure or service, Carriers shall permit all insured members who are legally authorized to consent to care, Bulletin 2017-02 April 21, 2017 Page 2 of 3 or parties legally authorized to consent to care for the insured member, to request suppression of a SOP for a specific service or procedure, in which case the SOP shall not be issued; provided, however, that the insured member clearly makes the request orally or in writing. The Carrier may request verification of the request in writing following an oral request. Carriers shall not require an explanation as to the basis for an insured member's request to suppress a SOP, unless otherwise required by law or court order. ## Delivery of Summary of Payments Forms Standard methods of delivery may include, but not be limited to, the following: (i) sending a paper form to the address of the subscriber; (ii) sending a paper form to the address of the insured member; or (iii) allowing the subscriber, the insured member, or both to access the form through electronic means; provided, however, that such access is provided in compliance with any applicable state and federal laws and regulations pertaining to data privacy and security. All Carriers shall permit any (i) subscriber who is legally authorized to consent to care for the insured member, (ii) insured member who is legally authorized to consent to her or his own care or (iii) other party who has the exclusive legal authorization to consent to care for the insured member, to choose in writing an alternative method of receiving the SOP, which shall include, but not be limited to, the following: (a) sending a paper form to the address of the subscriber; (b) sending a paper form to the address of the insured member; (c) sending a paper form to any alternate address upon request of the insured member or the member's legally authorized representative; or (d) allowing only the insured member or the member's legally authorized representative to access the form through electronic means; provided, however, that such access is provided in compliance with any applicable state and federal laws and regulations pertaining to data privacy and security. All Carriers shall also permit another party legally authorized to consent to care for an insured member to request and must accommodate a reasonable request by such third party to receive the forms on behalf of the member in any of the alternative methods listed in the paragraph above, provided that the third party clearly states in writing that the disclosure of all or part of the information could endanger the requesting party or the insured member. Upon receipt of such a request, Carriers shall not inquire as to the reasons for, or otherwise seek to confirm, the endangerment. The preferred method of receipt shall be valid until the insured member submits a request in writing for a different method; provided, however, that a Carrier shall not be required to maintain more than one alternate address for a member. Carriers shall comply with an insured member's request pursuant to this paragraph within 3 business days of receipt of the request. The insured member's ability to request the preferred method of receipt for SOPs and to request suppression of a SOP in the limited circumstances described in the paragraphs above shall be communicated in plain language and in a clear and conspicuous manner in evidence of coverage documents, member privacy communications and on every SOP, and shall be conspicuously displayed on the Carrier's member website and online portals for individual members. Bulletin 2017-02 April 21, 2017 Page 3 of 3 ## Compliance Requirements The Division shall issue requirements for reasonable reporting by Carriers to the Division regarding compliance and the number and type of complaints received regarding noncompliance with this Bulletin. Consumer complaints regarding alleged non-compliance with the requirements in this Bulletin may also be submitted by telephone to the Division's Consumer Services Section by calling (877) 563-4467 or (617) 521-7794. All complaints that are initially made verbally by telephone must be followed up by a written submission to the Consumer Services Section, which must include at least the following information requested on the Insurance Complaint Form: the complainant's name and address; the nature of complaint; and the complainant's signature authorizing the release of any information regarding the complaint to help the Division with its review of the complaint. The Division will endeavor to resolve all consumer complaints regarding non-compliance with this Bulletin in a timely fashion. In lieu of sending a SOP for every claim the Carrier pays, the Carrier may issue a document summarizing all claims paid during a reporting period no less frequently than quarterly. Carriers shall submit revised SOP forms to the Division by August 1, 2017. The Division expects Carriers to come into compliance with the Standards for Common Summary of Payments Forms and the Delivery of Summary of Payments Forms sections of this Bulletin no later than February 1, 2018, except for the requirement that electronic access be available for the delivery of SOP forms. Carriers shall have 24 months from the effective date of this Bulletin to provide electronic access to SOP forms; provided, however, that any carrier that has the capacity to provide electronic access to SOP forms prior to that date shall do so. Please direct any questions about this Bulletin to the Bureau of Managed Care of the Division of Insurance at (617) 521-7372 and BMC.mailbox@state.ma.us. # Bulletin 2017-02 # EXHIBIT A # COMMON SUMMARY OF PAYMENTS (SOP) FORMS The following elements must appear on the SOP in a format that is substantially similar to the chart shown. Billing and disposition information | Health care service provider name | | --- | | Date of service | | Type of service (high level description e.g., "office visit" not specific e.g., "cardiology visit" or "mental health visit") | | Service (provider) charge | | Health plan allowed amount and/or health plan discount | | Health plan covered | | Co-payment | | Coinsurance | | Applied to deductible | | Not covered by health plan | | Notes (denial code with explanation) | | Your share (insured's responsibility or amount provider will bill insured) | SUMMARY OF HEALTH PLAN PAYMENT | Health Care Service Provider | | | Health Plan Share | | | Your Cost Share | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Date of Service | Type of Service | Service Charge | Health Plan Discount | Health Plan Allowed Amount | Health Plan Covered | Copayment | Co-insurance | Applied to Deductible | Not Covered | Notes | Your Share | | Dr. Smith | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 01/01/2014 | Office Visit | $200.00 | $40.00 | $160.00 | $140.00 | $20.00 | $0.00 | $0.00 | $0.00 | EX | $20.00 | | 1/1/2014 | Lab | $100.00 | $20.00 | $80.00 | $80.00 | $0.00 | $0.00 | $0.00 | $0.00 | RS | $0.00 | | Subtotal | | $300.00 | $60.00 | $240.00 | $220.00 | $20.00 | $0.00 | $0.00 | $0.00 | | $20.00 | | Dr. Jones | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 01/01/2014 | Office Visit | $200.00 | $40.00 | $160.00 | $140.00 | $20.00 | $0.00 | $0.00 | $0.00 | EX | $20.00 | | 1/1/2014 | Lab | $100.00 | $20.00 | $80.00 | $80.00 | $0.00 | $0.00 | $0.00 | $0.00 | RS | $0.00 | | Subtotal | | $300.00 | $60.00 | $240.00 | $220.00 | $20.00 | $0.00 | $0.00 | $0.00 | | $20.00 | Explanation of notes: EX: RS: The following elements must appear on the SOP, but may be displayed in a format determined by the carrier. # General information Health plan name Statement date Claim number Patient name # Member information Subscriber's name and address Subscriber's ID number Insured's group name/number (as appropriate) # Bulletin 2017-02 EXHIBIT A COMMON SUMMARY OF PAYMENTS (SOP) FORMS # Plan information (when applicable) Individual deductible Family deductible Individual out-of-pocket maximum Family out-of-pocket maximum Individual deductible applied to date Family deductible applied to date Individual out-of-pocket maximum applied to date Family out-of-pocket maximum applied to date Definitions (use definitions substantially similar to those in the ACA Glossary of Health Coverage and Medical Terms as applicable) Allowed amount Health plan discount Health plan covered Service (provider) charge Copayment Coinsurance Deductible Out-of-pocket maximum Your share/You owe/ You owe Not covered # Other information Appeal rights/Information How to contact the carrier with questions/ customer service contacts Translation services available Consumer assistance Confidentiality statement (including alternate methods of receiving SOP)