Currentfallon_community_health_plan_incPolicy N/A

Serious Reportable Events and Provider Preventable Conditions Payment Policy

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Governs Fallon Community Health Plan reimbursement and reporting requirements for Serious Reportable Events (SREs), Serious Adverse Drug Events (SADEs), Provider Preventable Conditions (PPCs) across applicable Fallon products and all settings; affects network providers delivering covered services to Fallon members, with specific MassHealth ACO compliance requirements.

Policy Summary

Payerfallon_community_health_plan_inc

PolicySerious Reportable Events and Provider Preventable Conditions Payment Policy

Policy CodePolicy N/A

Change TypeAdded MassHealth Appendix V compliance language

Effective DateMar 1, 2026

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionSuspend or rescind any SRE/PPC-related claims pending preventability determination and report SRE/SADE to the Massachusetts Department of Public Health within 7 days.

SourceLink

POLICY UPDATE CHANGES

Added language requiring all Providers delivering covered services to MassHealth ACO members to comply with MassHealth All Provider Manuals Appendix V: MassHealth Billing Instructions for Provider Preventable Conditions.

7 daysinitial written SRE/SADE report to Department of Public Health after discovery

30 daysfollow-up preventability determination and report to DPH and Fallon Health

30 daysnon-reimbursement window for related readmissions/follow-up

6Fallon products listed as applicable

Allplace of service applicability

Reimbursement and Reporting Criteria

Reimbursement and reporting criteria

Reimbursement exclusions and exceptions for SREs, PPCs, and SADEs

The Plan does not reimburse providers for services that are attributable to Serious Reportable Events (SREs) or Provider Preventable Conditions (PPCs) as listed and defined by applicable federal and state guidance (including the NQF table of reportable events and 105 CMR 130.332).

The Plan will not reimburse for PPCs that violate federal requirements under Section 2702 of the ACA and federal regulations at 42 CFR 447.26.

No reduction in payment for a PPC will be imposed when the condition existed prior to the initiation of treatment by that provider (per 42 CFR 447.26(c)(2)).

The Plan does not reimburse providers for readmissions, follow-up care, remediation, or complications related to an SRE or PPC within 30 days of discovery of the event when care is with the same provider or a provider owned by the same parent organization.30 days

Providers must suspend or rescind any SRE/PPC-related claims pending a preventability determination; claims for SREs/PPCs must include appropriate Present on Admission (POA) indicators and PPCs must be reported through claims submissions as required.

Providers must comply with reporting timelines: submit an initial written SRE/SADE report to the Massachusetts Department of Public Health within 7 days of discovery and provide a 30-day follow-up including preventability determination, root cause analysis, corrective actions, and whether the hospital will seek reimbursement; follow MassHealth Appendix V billing instructions for PPCs and POA coding.7 days; 30 days

The Plan reserves the right to audit records related to SREs, SADEs, and PPCs and to handle disputes through the provider appeals process.

Coding and Present-on-Admission Guidance

Present on Admission (POA) indicatorsmixedCovered

POA indicators

All claims related to an SRE or PPC must contain the appropriate Present on Admission (POA) indicator as described in MassHealth Appendix V.

List guidance — SRE/PPC listings

Guidance overviewProviders must check federal and state guidance for the most up-to-date listings of SREs/PPCs; the policy includes a guide table of events that is subject to change.

Source lists includedPolicy contains a tabular guide of SREs, HCACs, OPPCs, and NCD-designated events (see surgical/invasive, infection, environmental, radiologic, and criminal event categories).

Action for providersRefer to current CMS (HAC/HCAC) lists, Massachusetts DPH designations, and state NCDs to determine which events meet SRE/PPC criteria prior to billing.

Updates and variabilityEvent classifications (HCAC/OPPC/NCD/SRE) and codes may be revised periodically; rely on federal/state issuances rather than the static table in this policy for final determinations.

Examples included in guide tableExamples in the policy table include wrong-site/patient/procedure, retained foreign objects, certain surgical site infections, catheter-associated infections, environmental and radiologic events, and others.

Claims Handling and Reporting Responsibilities

Documentation Required

Suspend claims and report SREs/PPCs to DPH; include 30‑day follow-up

Immediately suspend or rescind any SRE/PPC-related claims pending the preventability determination and required notifications; submit SRE/SADE initial and follow-up reports to the Massachusetts Department of Public Health within the specified timelines. The 30-day follow-up to DPH and Fallon Health must include a narrative of the SRE, root cause analysis, preventability analysis per 105 CMR 130.332(C)(1), corrective actions, and whether the hospital intends to seek reimbursement for services related to the SRE. Report PPCs through claims submissions and follow MassHealth Appendix V POA coding guidance.

Suspend or rescind SRE/PPC claims pending preventability determination (billing/coding guideline).
File initial written SRE report with MA DPH within 7 days of discovery and notify the member/representative (105 CMR 130.332).
Submit a 30-day follow-up report to DPH and Fallon Health including: narrative; root cause analysis; preventability analysis per 105 CMR 130.332(C)(1); corrective actions; and whether the hospital will seek reimbursement.
Report PPC occurrences and related services via claims submissions; if PPC is also an SRE, follow SRE reporting requirements.
Ensure all claims related to an SRE or PPC contain the appropriate Present on Admission (POA) indicator per MassHealth Appendix V.

Key Terms

Serious Reportable Event (SRE)

DefinitionAn event that occurs on premises covered by a hospital's license that results in an adverse patient outcome, is clearly identifiable and measurable, usually or reasonably preventable, and designated by the Massachusetts Department of Public Health and identified by EOHHS.

Key characteristicsClearly identifiable and measurable; usually or reasonably preventable; risk influenced by hospital policies and procedures.

Designation authorityDesignated as SREs by the Massachusetts Department of Public Health and identified by EOHHS.

Provider Preventable Condition (PPC)

DefinitionA condition that meets the definition of a Health Care Acquired Condition (HCAC) or an Other Provider Preventable Condition (OPPC) as defined by CMS in 42 CFR 447.26(b).

Regulatory referenceDefined by Centers for Medicare & Medicaid Services in federal regulations at 42 CFR 447.26(b).

Relation to reimbursementConditions meeting the PPC definition are subject to the Plan's non-reimbursement rules unless an exception applies (e.g., preexisting condition per 42 CFR 447.26(c)(2)).

OPPC and Serious Adverse Drug Event (SADE)

OPPC scopeOPPCs occur in any health-care setting and include two subcategories: mandatory National Coverage Determinations (NCDs) and Additional state-defined OPPCs that meet 42 CFR 447.26(b).

NCD examplesMandatory OPPC NCDs include wrong-site surgery, surgery on the wrong patient, and wrong surgical or invasive procedure performed on a patient.

SADE definition and outcomesSerious Adverse Drug Event (SADE): an untoward, preventable medical occurrence associated with a controlled substance that results in death, life‑threatening outcome, inpatient hospitalization or prolongation, persistent/significant incapacity, or congenital anomaly.

State-defined OPPCsAdditional OPPCs are state‑defined conditions that meet the federal requirements in 42 CFR 447.26(b).

Network Provider

DefinitionNetwork Provider: an appropriately credentialed and licensed individual, facility, agency, institution, organization, or other entity that has an agreement with the Plan (or any subcontractor) for delivery of services covered under the contract between the Plan and EOHHS.

ApplicabilityPolicy requirements (reporting, billing, reimbursement exclusions) apply to network providers delivering covered services to Fallon members under the Plan–EOHHS contract.

Credentialing requirementProvider must be appropriately credentialed and licensed and operate under an agreement with the Plan to be considered a network provider under this policy.

Policy Summary

Payerfallon_community_health_plan_inc

PolicySerious Reportable Events and Provider Preventable Conditions Payment Policy

Policy CodePolicy N/A

Change TypeAdded MassHealth Appendix V compliance language

Effective DateMar 1, 2026

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionSuspend or rescind any SRE/PPC-related claims pending preventability determination and report SRE/SADE to the Massachusetts Department of Public Health within 7 days.

SourceLink

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Serious Reportable Events and Provider Preventable Conditions Payment Policy

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Reimbursement and Reporting Criteria

Reimbursement and reporting criteria

Reimbursement exclusions and exceptions for SREs, PPCs, and SADEs

The Plan will not reimburse for PPCs that violate federal requirements under Section 2702 of the ACA and federal regulations at 42 CFR 447.26.

No reduction in payment for a PPC will be imposed when the condition existed prior to the initiation of treatment by that provider (per 42 CFR 447.26(c)(2)).

The Plan reserves the right to audit records related to SREs, SADEs, and PPCs and to handle disputes through the provider appeals process.

Coding and Present-on-Admission Guidance

Present on Admission (POA) indicatorsmixedCovered

POA indicators

All claims related to an SRE or PPC must contain the appropriate Present on Admission (POA) indicator as described in MassHealth Appendix V.

List guidance — SRE/PPC listings

Guidance overviewProviders must check federal and state guidance for the most up-to-date listings of SREs/PPCs; the policy includes a guide table of events that is subject to change.

Source lists includedPolicy contains a tabular guide of SREs, HCACs, OPPCs, and NCD-designated events (see surgical/invasive, infection, environmental, radiologic, and criminal event categories).

Action for providersRefer to current CMS (HAC/HCAC) lists, Massachusetts DPH designations, and state NCDs to determine which events meet SRE/PPC criteria prior to billing.

Claims Handling and Reporting Responsibilities

Documentation Required

Suspend claims and report SREs/PPCs to DPH; include 30‑day follow-up

Suspend or rescind SRE/PPC claims pending preventability determination (billing/coding guideline).
File initial written SRE report with MA DPH within 7 days of discovery and notify the member/representative (105 CMR 130.332).
Submit a 30-day follow-up report to DPH and Fallon Health including: narrative; root cause analysis; preventability analysis per 105 CMR 130.332(C)(1); corrective actions; and whether the hospital will seek reimbursement.
Report PPC occurrences and related services via claims submissions; if PPC is also an SRE, follow SRE reporting requirements.
Ensure all claims related to an SRE or PPC contain the appropriate Present on Admission (POA) indicator per MassHealth Appendix V.

Key Terms

Serious Reportable Event (SRE)

Key characteristicsClearly identifiable and measurable; usually or reasonably preventable; risk influenced by hospital policies and procedures.

Designation authorityDesignated as SREs by the Massachusetts Department of Public Health and identified by EOHHS.

Provider Preventable Condition (PPC)

DefinitionA condition that meets the definition of a Health Care Acquired Condition (HCAC) or an Other Provider Preventable Condition (OPPC) as defined by CMS in 42 CFR 447.26(b).

Regulatory referenceDefined by Centers for Medicare & Medicaid Services in federal regulations at 42 CFR 447.26(b).

Relation to reimbursementConditions meeting the PPC definition are subject to the Plan's non-reimbursement rules unless an exception applies (e.g., preexisting condition per 42 CFR 447.26(c)(2)).

OPPC and Serious Adverse Drug Event (SADE)

OPPC scopeOPPCs occur in any health-care setting and include two subcategories: mandatory National Coverage Determinations (NCDs) and Additional state-defined OPPCs that meet 42 CFR 447.26(b).

NCD examplesMandatory OPPC NCDs include wrong-site surgery, surgery on the wrong patient, and wrong surgical or invasive procedure performed on a patient.

State-defined OPPCsAdditional OPPCs are state‑defined conditions that meet the federal requirements in 42 CFR 447.26(b).

Network Provider

ApplicabilityPolicy requirements (reporting, billing, reimbursement exclusions) apply to network providers delivering covered services to Fallon members under the Plan–EOHHS contract.

Credentialing requirementProvider must be appropriately credentialed and licensed and operate under an agreement with the Plan to be considered a network provider under this policy.