Definitions

As used in 958 CMR 11.00, the following words shall have the following meaning: Accountable Care Organization or ACO. An organization certified by the Commission as an Accountable Care Organization pursuant to M.G.L. c. 6D, § 15. ACO or RBPO Participant. A Health Care Provider or entity that participates, through billing, in the Accountable Care Organization’s or Risk-bearing Provider Organization’s Alternative Payment Contract(s). Actively Practicing. A Health Care Professional who regularly treats patients in a clinical setting. Alternative Payment Contract. Any contract between a Provider or Provider Organization and a Health Care Payer, employer or individual, which utilizes alternative payment methodologies, as defined under M.G.L. c. 6D, § 1. 11.02: continued Authorized Representative. A patients’s guardian, conservator, holder of a power of attorney, health care agent designated pursuant to M.G.L. c. 210, family member, or other person authorized by the patient in writing or by law with respect to a specific internal appeal or external review, provided that if the patient is unable to designate a representative, where such designation would otherwise be required, a guardian, conservator, holder of a power of attorney, or family member in that order of priority may be the patient’s representative or may appoint another responsible party to serve as the patient’s Authorized Representative. If the Authorized Representative is a Health Care Provider, the patient must specify a named individual who will act on behalf of the Authorized Representative and a telephone number for that individual. Carrier. An insurer licensed or otherwise authorized to transact accident and 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; or 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. Commission. The Health Policy Commission established in M.G.L. c. 6D. External Review Agency. An independent review organization, which is an entity or company under contract with the Commission to conduct independent reviews pursuant to 958 CMR 11.00. Each External Review Agency shall be accredited by a national accrediting organization. Financial Affiliation or Financial Relationship. Any financial interest in a Carrier or RBPO or ACO provided that the term Financial Affiliation shall not include revenue received from a Carrier by a clinical reviewer for health services rendered to insureds. Health Care Professional. A physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with law. Health Care Provider or Provider. A Health Care Professional or facility. Internal Reviewer. An individual directed by the RBPO or ACO to review internal appeals, who has a clinical background with an active license to practice and who was not involved in the decision about which the Patient appealed and is not under direct supervision of the individual who made the decision about which the Patient appealed. Material Familial Affiliation. Any relationship as a spouse, child, parent, sibling, spouse’s parent, spouse’s child, child’s parent, child’s spouse, sibling’s spouse, domestic partner, aunt, uncle, foster parent or foster child. Material Professional Affiliation. Any Health Care Professional-patient relationship, any partnership or employment relationship, a shareholder or similar ownership interest in a professional corporation, or any independent contractor arrangement that constitutes a Financial Affiliation. Office of Patient Protection. The office within the Commission established by M.G.L. c. 6D, § 16. Patient. An individual who chooses or is attributed to the Risk-bearing Provider Organization or Accountable Care Organization for medical or behavioral health care, and for whom such services are paid under an Alternative Payment Contract with a Carrier, excluding Medicare, Medicare Advantage, and Medicaid patients. 11.02: continued 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 specialist care, and maintains continuity of care within the scope of his or her practice. Provider Organization. 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 health care payers for the payments of health care services; provided, however, 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 health care payers for payment for health care services. Risk-bearing Provider Organization or RBPO. A Provider Organization that has obtained a Risk Certificate from the Division of Insurance pursuant to 211 CMR 155.00: Risk-bearing Provider Organizations. 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 appeal. 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 under 958 CMR 11.21. 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 § 1861(dd)(3)(A) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(A)). Urgent Medical Need. The risk of serious harm to the Patient is so immediate that the provision of appealed services should not await the standard 14-day response time for an internal appeal or the standard 21-day response time for an external review. Urgent Medical Need may occur when a Patient is receiving emergency services, ongoing services, or the Patient has a Terminal Illness. Urgent Medical Need occurs where a delay may seriously jeopardize the health of the Patient or otherwise jeopardize the Patient’s ability to regain maximum function.