Definitions

A number of common words and expressions are specifically defined here. Whenever one of them is used in 130 CMR 450.000, or in a provider contract, it will have the meaning given in the definition, unless the context clearly requires a different meaning. When appropriate, definitions may include a reference to federal and state laws and regulations. Accountable Care Organization (ACO). An entity that enters into a population-based payment model contract with EOHHS as an accountable care organization, wherein the entity is held financially accountable for the cost and quality of care for an attributed or enrolled member population. ACOs include Accountable Care Partnership Plans, Primary Care ACOs, and MCO-administered ACOs. Accountable Care Partnership Plan. A type of ACO with which the MassHealth agency contracts under its ACO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis and is approved by the Massachusetts Division of Insurance as a health- maintenance organization (HMO) and is organized primarily for the purpose of providing health care services. Administrative Action. A measure taken by the MassHealth agency to correct or prevent the recurrence of an unacceptable course of action by a provider, including but not limited to the imposition of an administrative fine or other sanction. Applicant. A person who completes and submits an application for MassHealth, and is awaiting the decision of eligibility. Audit. An examination by the MassHealth agency of a provider’s practices by means of an on-site visit, a review of the MassHealth agency’s claim and payment records, a review of a provider's financial, medical, and other records such as prior authorizations, invoices, and cost reports. The MassHealth agency conducts audits to ensure provider and member compliance with laws and regulations governing MassHealth. Behavioral Health Contractor. The entity contracted with EOHHS to provide, arrange for, and coordinate behavioral health care and other services to members on a capitated basis. Behavioral Health Services. Mental health and substance use disorder services. Billing Agent. Any individual or entity that contracts with a provider to act as the provider's representative for the preparation and submission of claims. Board of Hearings (BOH). The designated hearing unit within the Executive Office of Health and Human Services Office of Medicaid. Claim. A request by a provider for payment for a medical service or product, identified in a format approved by the MassHealth agency, that contains information including member and provider information, date of service, and description of service provided. Coverage Type. A scope of medical services, other benefits, or both that are available to members who meet specific eligibility criteria. 1. Introduction (130 CMR 450.000) Day. A calendar day unless a business day is specified. Eligibility Verification System (EVS). The member eligibility verification system accessible to providers. EVS also may be referred to as the Recipient Eligibility Verification System (REVS). Emergency Aid to the Elderly, Disabled and Children Program (EAEDC). A cash assistance program administered by the Department of Transitional Assistance for certain residents of Massachusetts that also covers certain medical services. The medical services component of the program is administered by the MassHealth agency. Emergency Medical Condition. A medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the member or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in § 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. § 1395dd(e)(1)(B). Emergency Services. Medical services that are provided by a provider that is qualified to provide such services, and are needed to evaluate or stabilize an emergency medical condition. Expedited Prior Authorization Decision. If the MassHealth agency receives an appropriately submitted and completed prior authorization request and determines that following the prior authorization request decision time periods in 130 CMR 450.303(A) could seriously jeopardize the member’s life or health, or if an expedited prior authorization decision is required by law, the MassHealth agency shall issue a prior authorization decision within 72 hours after receiving the prior authorization request. Final Disposition. A written response by a health insurer to a request for payment, such as a rejection notice, an explanation of benefits (EOB), or a similar letter, form, or other notice, by which the insurer either denies coverage, or acknowledges coverage and indicates the amount that the health insurer will pay. Group Practice. A legal entity that employs or contracts with individual practitioners who have arranged for the joint use of facilities, and for payment into a common account of proceeds from the delivery of medical services by individual practitioners within the group. A sole proprietorship is not a group practice. An entity that qualifies under the MassHealth agency’s program regulations as another discreet provider type, such as a community health center, is not a group practice. A “participant” in a group practice is any owner, employee, contractor, or provider delivering services through the group practice. Health Insurer. A private or public entity (including Medicare) that has issued a health insurance plan or policy under which it has agreed to pay for medical services provided to a member. Individual Practitioners. Physicians, dentists, psychologists, certified nurse practitioners, certified nurse midwives, physician assistants, certified registered nurse anesthetists, psychiatric clinical nurse specialists, clinical nurse specialists, and certain other licensed, registered, or certified medical practitioners. 1. Introduction (130 CMR 450.000) Managed Care. A system of primary care and other medical services that are provided and coordinated by a MassHealth managed care provider, a One Care Plan, a SCO Plan, or the behavioral health contractor in accordance with the provisions of 130 CMR 450.117 and 130 CMR 508.000: MassHealth: Managed Care Requirements. Managed Care Organization (MCO). Any entity with which the MassHealth agency contracts under its MCO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis, and is approved by the Massachusetts Division of Insurance as a health maintenance organization (HMO), and is organized primarily for the purpose of providing health care services. MassHealth. The medical assistance and benefit programs administered by the MassHealth agency pursuant to Title XIX of the Social Security Act (42 U.S.C. 1396a), Title XXI of the Social Security Act (42 U.S.C. 1397aa), M.G.L. c. 118E, and other applicable laws and waivers to provide and pay for medical services to eligible members. MassHealth Agency. The Executive Office of Health and Human Services in accordance with the provisions of M.G.L. c. 118E. MassHealth Enrollment Center (MEC). A regional office of the MassHealth agency that determines MassHealth eligibility of individuals and families who do not receive cash assistance (TAFDC, EAEDC, SSI). MassHealth Managed Care Provider. An MCO, Accountable Care Partnership Plan, Primary Care ACO, or the Primary Care Clinician Plan. MCO-administered ACO. A type of ACO with which the MassHealth agency contracts under its ACO program and which is administered through an MCO. Medicaid. See MassHealth. Medical Services. Medical care or related goods and services, including behavioral health services and long-term services and supports (LTSS) provided to members, paid or payable by the MassHealth agency. Medicare. A federally administered health insurance program for persons eligible under the Health Insurance for the Aged Act, Title XVIII of the Social Security Act. Member. A person determined by the MassHealth agency to be eligible for MassHealth. One Care Plan. An entity with which the MassHealth agency contracts under its One Care Program to provide care coordination and integrated medical care, behavioral health care, and long-term services and supports through a comprehensive provider network to dual eligible members ages 21 to 64 at the time of enrollment. One Care Plans are responsible for providing enrolled members with the full continuum of MassHealth and Medicare covered services. One Care Plans were previously referred to as integrated care organizations (ICOs). Overpayment. A payment made by the MassHealth agency to or for the use of a provider to which the provider was not entitled under applicable federal or state law or regulation. 1. Introduction (130 CMR 450.000) Over-the-counter Drug. Any drug for which no prescription is required by federal or state law. These drugs are sometimes referred to as nonlegend drugs. Party in Interest. A person with an ownership or control interest. Peer Review. An evaluation of the quality, necessity, and appropriateness of medical services provided by a provider, to determine compliance with professionally recognized standards of health care or compliance with laws, rules, and regulations under which MassHealth is administered. Prescription Drug. Any drug for which a prescription is required by applicable federal or state law or regulation, other than MassHealth regulations. These drugs are sometimes referred to as legend drugs. Primary Care. The provision of coordinated, comprehensive medical services, on both a first-contact and a continuous basis, to members enrolled in managed care. Services include an initial medical history intake, medical diagnosis and treatment, communication of information about illness prevention, health maintenance, and referral services. Primary Care ACO. A type of ACO with which the MassHealth agency contracts under its ACO program. Primary Care Clinician (PCC) Plan. A managed care option administered by the MassHealth agency through which enrolled members receive primary care and certain other medical services. Provider. An individual, group, facility, agency, institution, organization, or business that furnishes medical services and participates in MassHealth under a provider contract with the MassHealth agency. For purposes of applying 130 CMR 450.235 through 450.240, the term “provider” includes formerly participating providers. Provider Contract (Also Referred to as “Provider Agreement”). A contract for medical services between the MassHealth agency and a provider. Provider Service Restrictions. Sanctions placed by the MassHealth agency on a provider that include, but are not limited to, restrictions on services for which a provider may submit claims to and receive payment from the MassHealth agency, and restrictions on the number or particular members to whom a provider may provide services. Provider Type. A provider classification specifying and limiting the kinds of medical services for which the provider may be paid by the MassHealth agency. Provider under Common Ownership. Two or more providers in which a person or corporation has or had, at any time, an ownership or control interest, whether concurrently, sequentially, or otherwise. (See 130 CMR 450.221(A)(9)(a) and (b).) Sanction. An administrative penalty imposed by the MassHealth agency pursuant to M.G.L. c. 118E, § 37 against a provider found to have violated MassHealth laws, regulations, or contract requirements. Sanctions include, but are not limited to, administrative fines, provider service restrictions, suspension, and termination from participation in MassHealth. 1. Introduction (130 CMR 450.000) Senior Care Options (SCO) Plan. An entity with which the MassHealth agency contracts under the SCO Program to provide coordinated care and medical services, behavioral health care, and long-term services and supports through a comprehensive network to dual eligible members 65 years of age or older. SCO Plans are responsible for providing enrolled members with the full continuum of MassHealth and Medicare covered services. Standard Prior Authorization Decision. A prior authorization decision that is not an expedited prior authorization decision. For standard prior authorization decisions, the MassHealth agency acts on appropriately completed and submitted prior authorization requests within the times specified in 130 CMR 450.303(A). Except where an expedited prior authorization decision is required by law, incomplete or inappropriately submitted prior authorization requests will be acted on in accordance with 130 CMR 450.303(C)(2). Statutory Prerequisite. Any license, certificate, permit, or other requirement imposed by state or federal law or regulation as a precondition to the practice of any profession or to the operation of any business or institution in or by which medical services are provided. Statutory prerequisites include, but are not limited to, licenses required by the Massachusetts Department of Public Health or the Massachusetts Department of Mental Health, licenses and certificates issued by the Massachusetts boards of registration, and certificates required by the Massachusetts Department of Public Safety. Third Party. Any individual, entity, or program other than the MassHealth agency that is or may be liable to pay for the provision of medical services in whole or in part. Transitional Aid to Families with Dependent Children (TAFDC). A federally funded program administered by the Massachusetts Department of Transitional Assistance that provides cash assistance to certain low-income families. Urgent Care. Medical services that are not primary care, and are needed to treat a medical condition that is not an emergency medical condition.