129 CMR 4.00 — Disclosure of health care claims data to a provider

129 CMR: HEALTH CARE QUALITY AND COST COUNCIL 129 CMR 4.00:DISCLOSURE OF HEALTH CARE CLAIMS DATA TO A PROVIDER Section 4.01: General Provisions 4.02: Definitions 4.03: Data Disclosure Procedures

129 CMR 4.00 Disclosure of health care claims data to a provider

4.01 General Provisions

4.01: General Provisions (1) Authority. 129 CMR 4.00 is promulgated under the authority of and in conformity with M.G.L. c. 6A, §§ 16J, 16K and 16L. (2) Scope and Purpose. 129 CMR 4.00 governs the disclosure to providers of Health Care Claims Data submitted by Carriers to the Health Care Quality and Cost Council. The purpose of 129 CMR 4.00 is to provide for disclosure of a particular provider’s claims data to that provider for the purpose of verifying the accuracy of the provider’s data. (3) Effective Date. 129 CMR 4.00 is effective on May 23, 2008.

4.02 Definitions

4.02: Definitions The following words shall have the following meanings: Carrier. Any entity subject to the insurance laws and rules of Massachusetts, or subject to the jurisdiction of the commissioner of insurance, that contracts or offers to provide, deliver, arrange for, pay for, or reimburse any of the costs of health services, including an insurance company, a health maintenance organization, a nonprofit hospital services corporation, a medical service corporation, third-party administrator or any other entity arranging for or providing insured health coverage. Council. The Health Care Quality and Cost Council established under M.G.L. c. 6A, § 16K. Disclosure. The release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information. Health Care Claims Data. Information consisting of, or derived directly from, member eligibility information, medical claims, pharmacy claims, and all other data submitted by health care claims processors pursuant to 129 CMR 2.00. Provider. A health care practitioner, health care facility, health care group, medical product vendor or pharmacy.

4.03 Data Disclosure Procedures

4.03: Data Disclosure Procedures (1) The Council may disclose to a Provider some or all of a Carrier’s Health Care Claims Data that the Carrier received from that particular provider and submitted to the Council pursuant to M.G.L. c. 6A, § 16L(d) and 129 CMR 2.00. The Provider may submit, in writing and within a time period specified by the Council, comments to the Council regarding the Health Care Claims Data. The Council shall consider any such timely submitted comments prior to publication of data on the Council’s website. (2) The Provider shall maintain the confidentiality of the Health Care Claims Data it receives from the Council. The provider shall not disclose the Health Care Claims Data except to the Council or as otherwise provided by applicable state or federal law. REGULATORY AUTHORITY 129 CMR 4.00: M.G.L. c. 6A, §§ 16J, 16K and 16L.

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