114.5 Cmr: Division of Health Care Finance and Policy s1

114.5 114.5CMR: CMR: DIVISION DIVISION OF HEALTH OF HEALTH CARE CARE FINANCE FINANCE AND POLICYAND POLICY

114.5 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY Health Plan Information. 22.03:22.02: continued114.5 continued CMR 22.00:6. The HEALTHDivision will CARE post CLAIMS applications DATA on the RELEASE Division's website. The Division will not post those portions of applications that specify security measures or applications from law Section PublicInformation Useenforcement1. the Files submitted purpose. Public entities forby Use whichHealth toFiles the the Care areextent data Payersdatasets is that requested in postingderived accordance is the fromin theapplication withrecords public interest.submitted on the websiteUses by payers that may serve pursuant impede the toProvider114.5 114.5 CMRthepublic .CMR A investigatory health21.03(2). interest 21.00 care that include, practitioner, process. contain but de-identified Theare health notDivision limited care member facility,will to: invitehealth healthand publiccost utilization care and comments group, utilization data medical elementson analysis applications product and to exclude for at 22.01: Generalpayervendor Provisions identifiers. orleastformulate pharmacy. ten business publicPublic policy; daysUse Filesfollowing financial contain the studies daydata onand elements which analyses the that applicationof willprovider not isbepayment posted disclosed systems;on the unless website. the 22.02: DefinitionsDivision Publicutilization determines comments review that an studies;that applicant comply health fulfills with planning all the applicable requirements and resource internet imposed allocation policies by studies; 114.5 for public CMR and studies posting that will 22.03: Procedures22.03. for Seebepromote Data posted 114.5 Requests improvement CMRon the 22.07:Division's in Appendix health website. care A quality - Public or Usea mitigation Data Elements of health Table care for cost list growth. of Public 22.04: Data DisclosureUse(b) elements. Data Restrictions Release Criteria. The Commissioner will approve an application if he or she 22:05: Other Provisionsdetermines2. the applicantthat: has demonstrated it is qualified to undertake the study or accomplish the 22.06: SeverabilityRestricted intended Use Files use;. Restricted Use Files are datasets derived from records submitted by payers 22.07: Appendixpursuant A -3. Publicto the 114.5 applicant Use CMR Data requires Elements21.00 thatsuch Table containdata in orderdata elementsto undertake that the will study not orbe accomplish disclosed unlessthe the 22.08: AppendixDivision B -intended Restricteddetermines use; Use thatand Data an applicantElements fulfillsTable the requirements imposed by 114.5 CMR 22.03(2). See 114.54. theCMR applicant 22.08: can Appendix ensure thatB - patientRestricted privacy Use willData be Elements protected. Table for list of Restricted 22.01: GeneralUse Provisions(c) elements. Data Release Committee. The Commissioner shall establish a Data Release Committee to advise the Commissioner on individual applications for claims data upon the request of the 22.03: Procedures(1) ScopeCommissioner. for Dataand PurposeRequests In .addition, 114.5 CMR the Committee22.00 governs provides the disclosure advice on of best health practices plan information regarding claimsand claimsdata data release submitted and data by protectionhealth care policies. payers pursuant to 114.5 CMR 21.00. The purpose of 114.5(1) Public CMR1. Theand 22.00 RestrictedCommittee is to make Use shall healthFiles include,. Theplan but Divisioninformation not be will limited and create data to, Claims representation available Data as Public a resourceof health Use Fileswherecare plans,and such accessRestricted servesproviders, Use the Files public and to consumers.which interest Applicants while The safeguardingCommissioner may request the accessmay privacy appoint in accordancerights additional of claims with members data 114.5 subjects. CMR to the Pursuant22.03(2).Committee. to M.G.L. c. 118G, § 6, data submitted by health care payers are not a public record, and no public2. disclosureThe Commissioner of any data shall and convene information the Committee shall be made as necessary, except in accordanceand post the with agenda the of the provisions(2) ApplicationCommittee of 114.5 Review onCMR the Procedures 22.00.Division's . website. When convening the Data Release Committee, the (a) Commissioner Applications for shall Data concurrently. consult with one or more representatives of the state (2) Effective1.agencies All Date Applicants that. 114.5 participate CMR must 22.00 submitthrough is aeffective intergovernmentalwritten application.July 23, 2010. services Each Applicant agreement(s) shall: in 114.5 CMR 21.00..1 specify the data requested, including Public Use Files and any (3) Authority3. Advicerestricted. 114.5 issued dataCMR by elements the22.00 Data is requested; adoptedRelease pursuantCommittee to M.G.L.is not binding c.118G. on the Commissioner. 4. The.2 Divisionspecify thewill purpose post information and intended about use the of Datathe data Release requested, Committee's including membership, a 22.02: Definitions scheduleddetailed meetings project descriptionand meeting that agendas describes on the any Division's other data website. sources to be used (d) The forCommissioner's the project; decisions to approve or deny claims data release applications are final Asand used not .3subject in 114.5specify to CMRfurther security 22.00, review and theprivacy or followingappeal. measures words that shall will havebe taken the infollowing order to meanings: (e) Thesafeguard Commissioner patient may privacy impose and conditions to prevent on unauthorized the subsequent access use to and or disclosureuse of of data releasedsuch under data; 114.5 CMR 22.00. Applicant. .4An individualspecify the or Applicant's organization methodology that requests for health maintaining care data data and integrity information and in accuracy; accordance .5withdescribe 114.5 CMR how 22.03.the results Claims of the Data Applicant's. Information analysis consisting will be of, published; or derived directly from, member.6 eligibility agree to provide the results of all analyses, research, or other product information,of medical, the data pharmacy, requested toor thedental Division claims for and the encounters, Division's andown all use; other data submitted by Health Care.7 Payersagree in to accordance the data disclosure with 114.5 restrictions CMR 21.00. in 114.5 CMR 22.04; and .8 obtain prior approval from the Division to release any reports that used CMS. The federalrestricted Centers use files for Medicareprior to publication and Medicaid or other Services. release Data to another Use Agreement person or. A entity. The Division will review the report to determine whether the document detailingprivacy rightsrestrictions of any on data the subjectDisclosure would and be use violated of Claims by the release of the report Data. 1. Applicants for Public Use Files shall specify which pre- developed module of public use files is requested. Additional or Disclosure. Thecustomized release, transfer, public provision use files willof, access only be to, provided or divulging at the in any manner of Health Commissioner's sole discretion; Plan Information2. or Claims Applicants Data. Division for Restricted. The Division Use Files of mustHealth demonstrate Care Finance a need and Policy established underfor M.G.L. each restricted c. 118G. data Health element Care requested.Payers. A Payer The Division required will to submit release health care only those restricted data elements which it determines to be necessary information andto data accomplish under the applicant's intended use; 114.5 CMR 21.00.3. Applicants requesting Medicare data will be required to conform with CMS requirements to obtain and use applicable data. 4. Medicaid data will not be released in response to any application, unless the release of such data conforms to all applicable federal and state laws and regulations, including laws and regulations governing the de-identification of such data, and any data release restrictions in the agency's interagency service agreement. 5. 114.5 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

22.04: continued (c) restricted data elements will not be released to any other person or entity except as specified in 114.5 CMR 22.04(2); and (2) Other(d) the Government applicant will Agencies obtain these. The assurancesDivision may in writingrelease fromclaims any data recipient to: of data or agent (a)that processesa state agency data oron authoritybehalf of whichthe applicant. has, pursuant to its statutory or regulatory authority, directed third parties to submit data as required by statute, regulation or contract, to the Division in fulfillment of its legal or regulatory obligation. The Division will release claims data only to the state agency or authority with such legal authority, or as directed by such agency or authority to legally authorized entities. (b) organizations under contract with the Division to undertake studies; and (c) other government agencies whose applications meet the criteria set forth in 114.5 CMR

(3) Other Disclosures. The Division or its agent may release draft reports or other analyses that contain or use restricted use claims data for review and comment. If the Division or its agent provides an individual or entity with a draft report or other analysis for review and comment, the contents of such report or the analysis contained in such report are confidential, and may not be disclosed without prior approval by the Division. The report must conform to the standards for de- identification set forth under 45 CFR 165.514(a), (b)(2), and (c).

(3) The Division may charge a fee to all applicants requesting claims data, as established under M.G.L. c. 7, § 3B and approved by the Executive Office for Administration and Finance. Established fees shall reflect the total cost of systems analysis, program development, computer production costs incurred in producing the requested data, vendors' fees, consulting services, and any other costs related to production of the requested data. Fee schedules will be issued by the Division by Administrative Bulletin. The fee may be waived for the following entities: (a) CMS; (b) an agency of the Commonwealth; or (c) researchers who can demonstrate that imposition of a fee would constitute an undue hardship.

22.04: Data Disclosure Restrictions

(1) Required Assurances. All applicants shall provide the Division with written assurances that:

(a) data will be used only for the purpose stated in the request; (b) no attempt will be made to use any data supplied to ascertain the identity of specific insured individuals or patients; 114.5 114.5CMR: CMR: DIVISION DIVISION OF HEALTH OF HEALTH CARE CARE FINANCE FINANCE AND POLICYAND POLICY

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The Division shall institute appropriate administrative procedures and BillingPrescribingIdentificationMedicaidEthnicityScreening,NumberUses EMR Provider Product 1Id Diagnosis indicatorPhysician Medicaid NumberIdentification EMR and Firstassigned Treatment VendorName Number number Electronic (EPSDT) Paidfor the Date Medical Procedure Paid Record date CodeBillingService of defineIndicatesVendorname theTypeFirst Provider claimProvider nameClaimif Insurance ifline VisionNumber of lineAccepting AllowedPrescribing Procedure Servicesis Amount New Physician areCode Patients a covered Type mechanisms to ensure that it is in compliance with the provisions of M.G.L. c. 66A, to the extent ServicePrescribingNationalMedicalAllowedIndicates Provider and BillingAmountif providerPhysician Pharmacy ProviderSuffix Tooth or Middle providerDeductible Number/Letter ID Name group Tooth NumberNumber or(PlanID) NationalLetterProviderMiddleProviderbenefit IdentificationPayer Provider Nameinitial in Claimin the PV002 Suffixof Identificationmember's PrescribingControl Dental QuadrantNumbereligibility Physician(NPI) Payer that the claims data collected is "personal data" within the meaning of that statute, and the security ServicePrescribingClaimEthnicityDental ControlQuadrant Provider 2 Physician Identification ToothSpecialty Last Surface Name Insured Tooth Group Service or IdentificationPolicyNumberDOB Date Number (PlanID) ofProvider'sSpecialty theClaim Carriers BillingLast Insured Line dateCodename groupProvider Type Groupof of birth orPrescribing Claim orpolicy Policy Line number PhysicianNumberActivity provisions of the Health Insurance Portability and Accountability Act. 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