Massachusetts Regulations 452.6.02

Authorization means notification by an insurer to the provider that specific, medically necessary health care services will be reimbursed by the insurer pursuant to M.G.L. c. 152.

Bill means a request by a provider that is submitted to an insurer or utilization review agent for payment for health care services that are provided in connection with a compensable injury or illness pursuant to M.G.L. c. 152.

Case Record means the complete health care record that is maintained by the insurer and pertains to an employee's injury or illness. The case record shall include all the following information and documents: the circumstances or reasons for seeking health care, all bills filed by the provider, and any actions of the insurer.

Commissioner means the Commissioner of the Department of Industrial Accidents (DIA).

Department means Department of Industrial Accidents (DIA).

Detailed Description of Services Rendered means pursuant to M.G.L. c. 152, Sec. 13 a report demonstrating the diagnosis, medical appropriateness of the service, pertinent physical findings, diagnostic and therapeutic procedures, prognosis, concurrent problems, and follow-up care; the injured employee's functional limitations, the ability to perform either regular duties, limited duties, full or part time hours and/or whether the medical condition is at a point of maximum medical improvement.

Diagnostic Procedure means a service that aids in determining the nature and cause of a disease or injury.

Diagnostically Related Groups means codes that refer to certain classes of diagnoses for prospective payment purposes by which health care providers are paid a pre-set amount for treatment of a particular medical ailment.

Dispute means a disagreement between an insurer, an employee, a provider or any other party concerning the application of M.G.L. c. 152.

Emergent Admission means placement of an employee in a facility for the care of a work-related medical condition of an unforeseen or rapidly progressing nature.

Facility means any location intended as a site for medical treatment.

Functional Status means the standardized measurement of a patient's self-reported ability to function including, but not limited to, Medical Outcome Study Short Form (MOS-SF)--36.

Guidelines mean optimal strategies for patient management around which practice patterns should converge.

Health Care Services means treatment services rendered to an injured employee by a provider pursuant to M.G.L. c. 152.

Health Care Services Board means the Board created by M.G.L. c. 152, Sec. 13(3).

Injury means personal injury as defined in M.G.L. c. 152, Sec. 1(7A).

Inpatient Care means that care which requires an employee to stay overnight in a facility.

Insurer means an entity defined in M.G.L. c. 152, Sec. 1(7) and any self insured group as defined in M.G.L. c. 152, Sec. 25(E)-(U).

Medical Condition means the physical or mental health status of an injured employee as determined by the provider administering health care services.

Medical Release means a signed release by the injured employee authorizing release of all relevant medical information regarding the injury.

Medical Report means a report of the Initial Industrial Accident office visit as defined in 114.3 CMR 40.03 pursuant to 452 CMR 1.13(1).

Non-emergent (Elective) Admission means placement of the employee in a facility for care of a condition which may be appropriately scheduled in advance.

Outpatient Care means that care which does not require an overnight stay in a facility.

Patient Satisfaction Measurement means use of a standard patient questionnaire form, including, but not limited to, the American College of Physicians questionnaire to determine a particular individual's satisfaction with his or her care.

Practitioner means a person who is a physician or dentist as defined by M.G.L. c. 233, Sec. 79G.

Preferred Provider Arrangement (P.P.A.) means a contract between or on behalf of an organization and health care provider(s), as defined by M.G.L. c. 176I, 211 CMR 112.00 and M.G.L. c. 152, to provide all or a specified portion of health care services resulting from workers' compensation claims against such organizations by covered persons.

Procedure means a unit of health care service.

Provider means a practitioner, facility, or other organization providing health care services.

School means a grouping of practitioners as defined by their professional degree. Schools include, but are not limited to, physical and occupational therapy, chiropractic, osteopathic, allopathic, nursing and dentistry.

Utilization Review means a system for reviewing the appropriate and efficient allocation of health care services given to a patient or group of patients as to necessity, for the purpose of recommending of determining whether such services should be covered or provided by an insurer, provider, nonprofit service organization, third-party administrator or employer. Included are those programs or processes whether they apply prospectively, concurrently, or retrospectively to health care services. Utilization review services include, but are not limited to, the following: second opinion programs; pre-hospital admission certification; pre-inpatient service eligibility certification; and concurrent hospital review to determine appropriate length of stay.

Utilization Review Agent means any person or entity, including the Commonwealth of Massachusetts or any insurer which has developed its own utilization program, performing utilization review. Utilization review agent shall not mean an agency of the federal government; or an agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government; or a hospital's internal quality assurance program; or health maintenance organizations licensed and regulated by the Commissioner of the Division of Insurance, but only to the extent of providing utilization review to their own members.