General Reporting Requirements

(1) Annual Reports. (a) Each Payer shall file annually its TME by Physician Group, Physician Local Practice Group, and Member Zip Code, and its Relative Prices for Hospitals, Physicians, and Other Providers in accordance with the requirements of 114.5 CMR 23.04 and 23.05. (b) A Private Health Care Payer is subject to the reporting requirements in 114.5 CMR 23.00 if: 1. The Payer is a Surcharge Payer and the Payer's Payments Subject to Surcharge placed the Payer at the company level within the top 12 Surcharge Payers for the period October 1, 2009 through September 30, 2010 as determined by the Division and posted on the Division's website; or 2. The Payer contracts with the office of Medicaid, the Commonwealth Health Insurance Connector, or the Group Insurance Commission to pay for or arrange for the purchase of health care services on behalf of individuals enrolled in health coverage programs under Titles XVIII, XIX, or XXI, under the Commonwealth Care Health Insurance program, Medicaid managed care organizations, or under the Group Insurance Commission. 3. If a Private Health Care Payer subject to the reporting requirements of 114.5 CMR 23.00 makes separate surcharge payments under 114.6 CMR 14.00 for individual plans or clients the Payer shall file the required data for all of its plans or clients. (c) Public Health Care Payers may provide data to the Division pursuant to an interagency service agreement. (2) Data Submission Requirements. (a) Each Payer shall submit data directly to the Division in electronic format. Data submissions must conform with edit specifications as set forth in the Data Specification Manual. The Division will notify a Payer whether the submission has been accepted or rejected. Payers must correct and resubmit rejected data until notified that the submission has been accepted. (b) Each Payer's chief executive officer or chief financial officer shall certify under pains and penalties of perjury that all reports and records filed with the Division are true, correct and accurate. (c) The Division may request that a Payer submit additional documentation of reported TME and Relative Prices. Payers must submit documentation requested by the Division within 15 business days from the date of the request, unless the Division specifies a different date. The Division may, for cause, extend the filing date of the requested information, in response to a written request for an extension of time. (d) The Division may amend data specifications and filing deadlines by Administrative Bulletin. (3) Penalties. (a) If a Payer fails to submit required data to the Division on a timely basis, or fails to correct submissions rejected because of errors, the Division shall provide written notice to the Payer. If the Payer fails to provide the required information within two weeks following receipt of said written notice, the Division will take all necessary steps to enforce this provision to the fullest extent of the law. (b) Private Health Care Payers that do not comply with the reporting requirements of 114.5 CMR 21.00 are subject to a penalty of up to $1,000 per week for each week that the Payer fails to provide the required data, up to a maximum of $50,000 in accordance with M.G.L. c. 118G, § 6. (c) The Division will notify the Attorney General's Office to enforce the provisions of 114.5 CMR 23.03(3)(a) and (b).