Section 3.600 - Reporting Requirements(1) Carriers shall provide the following information to the Office of Patient Protection no later than April 1st of each year, with the exception of the materials required under 958 CMR 3.600(l)(e), which shall be submitted concurrent with their submission to the Division of Insurance for parity certification under M.G.L. c. 26, § 8K, and 958 CMR 3.600(l)(f), which shall be submitted concurrent with their submission to the Division of Insurance. Such information shall be submitted in a manner specified by the Office of Patient Protection or using a template or form developed by the Office of Patient Protection. Unless concurrent submission is required, where the carrier is also providing the requested information or materials to the Division of Insurance within the same calendar year, the related element of the reporting requirement to the Office of Patient Protection may be satisfied by providing a written statement to the Office of Patient Protection describing which information or materials are being provided to the Division and on what date the carriers will provide the information or materials to the Division. (a) a list of sources of independently published information assessing insureds' satisfaction and evaluating the quality of health care services offered by the carrier;(b) the percentage of physicians and nurse practitioners who voluntarily and involuntarily terminated participation contracts with the carrier during the previous calendar year for which such data has been compiled and the three most common reasons for voluntary and involuntary provider disenrollment;(c) the medical loss ratio, which is percentage of premium revenue expended by the carrier for health care services provided to insureds for the most recent year for which information is available;(d) a report detailing, for the previous calendar year:1. the total number of filed grievances, the type of medical or behavioral health treatment at issue where applicable, the number of grievances that were approved internally, the number of grievances that were denied internally, and the number of grievances that were withdrawn before resolution;2. the number of grievances which resulted from an adverse determination, the type of medical or behavioral health treatment at issue, and the outcomes of those grievances; or if this information is also being reported to the Commissioner of Insurance on or prior to July 1st, a statement to that effect;3. the percentage of insureds who filed internal grievances with the carrier;4. the total number of internal grievances that were reconsidered pursuant to 958 CMR 3.308, the number of reconsidered grievances that were approved internally, the number of reconsidered grievances that were denied internally, and the number of reconsidered grievances that were withdrawn before resolution;5. the total number of external reviews pursued after exhausting the internal grievance process, and the resolution of all such external reviews. The report shall identify, for each such category, to the extent such information is available, the demographics of such insureds, which shall include, but need not be limited to, race, gender and age. 958 CMR 3.600(l)(d)2. through 4. shall take effect for reports due to the Office of Patient Protection on and after April 1, 2015.
(e) a report detailing the information required to be reported pursuant to M.G.L. c. 1760, § 7(b)(5), in a manner and form to be specified by the Office of Patient Protection. 958 CMR 3.600 (1)(e) shall take effect for reports due to the Office of Patient Protection in 2018.(f) An electronic copy of the following, which are required to be provided upon enrollment to at least one adult insured in each household residing in Massachusetts pursuant to M.G.L. c.1760, §§ 6 and 7(a):1. Evidence of coverage and any amendments thereto;2. A list of health care providers in the carrier's network, organized by specialty and by location and summarizing for each such provider the method used to compensate or reimburse such provider, provided, however, that disclosure of the specific details of any financial arrangements between a carrier and a provider is not required;3. A statement that physician profiling information, so-called, may be available from the board of registration in medicine;4. A summary description of the process by which clinical guidelines and utilization review criteria are developed;5. The voluntary and involuntary disenrollment rate among insureds of the carrier;6. A statement that insureds have the opportunity to obtain health care services for an emergency medical condition, including the option of calling the local pre-hospital emergency medical service system, whenever the insured is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services; and7. A statement that the information specified in 958 CMR 3.600(l)(a) through (d) is available to the insured or prospective insured from the Office of Patient Protection.(2) Carriers shall provide to the Office of Patient Protection, concurrent with the submission to the Center for Health Information and Analysis pursuant to M.G.L. c. Ill, §217, a copy of the health plan data and information set compiled for the National Committee on Quality Assurance or other information collected by the carrier and deemed to be similar or equivalent thereto. At the carrier's option, proprietary financial data may be excluded from this submission.(3) Each carrier shall provide to the Office of Patient Protection no later than April 1st of each year, information to assist the Office of Patient Protection in resolving appeals.(a) Each carrier shall provide the name, telephone number and e-mail address of the person or persons within its organization who will serve as the general contact for the Office of Patient Protection for appeals and grievances.(b) Each carrier shall provide the name, telephone number and e-mail address of the person or persons who have the authority to approve appeals and approve the payment of claims for all products and for all types of services.(c) If any of this contact information changes, the carrier shall provide the new information in writing to the Office of Patient Protection within ten business days following the change.(4) The confidentiality of any information about a carrier or utilization organization which, in the opinion of the Office of Patient Protection in consultation with the Division of Insurance, is proprietary in nature shall be protected, except where disclosure is otherwise required by law.(5) The Office of Patient Protection shall establish a site on the internet and through other communication media, make managed care information collected by the Office of Patient Protection readily accessible to consumers. The internet site shall, at a minimum, include:(a) a chart comparing the information obtained on premium revenue expended for health care services as provided pursuant to 958 CMR 3.600(l)(c) for the most recent year for which information is available; and(b) data collected pursuant to 958 CMR 3.600(2).Amended by Mass Register Issue S1331, eff. 1/27/2017.Amended by Mass Register Issue 1494, eff. 4/28/2023.