Reporting Requirements for All Licensed Carriers

(1) HEDIS ReportingRequirements. Eachcarrier that collects data for use in calculating health plan employer data and information set managed care measures shall report those data that are collected and that pertain to Massachusetts resident members or subscribers who receive their benefits under a policy or plan issued in Massachusetts. The carrier shall use the NCQA tool for submission of HEDIS data. (2) CAHPS Reporting Requirements. Each carrier that collects CAHPS survey data shall report those data collected that are collected and that pertain to Massachusetts resident members or subscribers who receive their benefits under a policy or plan issued in Massachusetts. The carrier shall use the NCQA format for submission of the CAHPS survey data. (3) Health Claims Dataset. Each carrier shall submit to the Council, or its designee, a completed health care claims data set for all Massachusetts resident members who receive services under a policy issued in Massachusetts. Each carrier shall also submit all health care claims processed by any sub­ contractor on its behalf. The health care claims data set shall include a member eligibility file, a medical claims file, and a pharmacy claims file. (4) Health care claims processors may submit all of the data submissions required of carriers under 129 CMR 2.00, in accordance with the specifications in129 CMR2.05(1) through(4), to the extent permitted by law and contractual requirements. (5) Exceptions to Reporting Requirements. (a) Third party payers that write less than $250,000 in insured accident and health premiums in Massachusetts on an annual basis shall not be required to submit their health care claims data set, their HEDIS data, or their CAHPS survey data. (b) Third party administrators that administer insured health insurance plans covering fewer than 200 Massachusetts lives in total shall not be required to submit their health claims data. (c) Carriers shall not be required to submit claims for stand-alone insurance policies that cover only one or more of the types of services listed in 129 CMR 2.05(5)(c)1. through 8.; however claims for these types of services shall be included in the medical claims file submission if they are covered by a comprehensive medical insurance policy. 1. Specific Disease; 2. Accident; 3. Injury; 4. Hospital Indemnity; 5. Disability; 6. Long-term Care; 7. Vision Coverage; or 8. Durable Medical Equipment. (d) In instances where more than one entity is involved in the administration of a policy, the health carrier shall be responsible for submitting the claims data on policies that it has written, and the third party administrator shall be responsible for submitting claims data on self-insured plans that it administers.