CurrentMass General Brigham Health PlanPolicy N/A

Provider Reporting and Reimbursement for SREs, PPCs, and SADEs

Governs provider reporting requirements and payment/reimbursement treatment for Serious Reportable Events (SREs), Provider Preventable Conditions (PPCs), and Serious Adverse Drug Events (SADEs) across outpatient, inpatient, and other provider settings.

Policy Summary

PayerMass General Brigham Health Plan

PolicyProvider Reporting and Reimbursement for SREs, PPCs, and SADEs

Policy CodePolicy N/A

Change TypeAnnual review / clerical updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit SRE form via fax for medical events within 7 days and the 30-day report including RCA as required.

SourceLink

POLICY UPDATE CHANGES

January 1, 2025 annual review, no policy change

January 1, 2024 annual review, no policy change

Document rebrand and updated references on January 1, 2023

7 daysinitial report timeframe

30 days30-day report (RCA)

5-10 business daysitemized bill turnaround

30 daysreadmission non-reimbursement window

Fax 617-526-1916medical SRE fax

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Reimbursement and Coverage Rules for SREs / PPCs

Reimbursement stance and operational rules

Reimbursement and operational rules for events designated as Serious Reportable Events (SREs) or Provider Preventable Conditions (PPCs).

Mass General Brigham Health Plan does not reimburse services associated with SREs or PPCs; when payment has been made for services associated with an SRE or PPC, the Plan is entitled to retract reimbursement previously made to the provider.

Providers are prohibited from collecting member liability amounts (copayment, coinsurance, deductible) or balance billing members for events and/or post-event related services that are designated as ineligible for payment.

No reimbursement will be provided for readmissions or follow-up treatment related to an SRE, remediation or complication due to an SRE within 30 days of discovery of the event when the care is with the same provider or a provider owned by the same parent organization.

The Plan will reimburse eligible providers who accept transferred patients for post-event care at another institution or under the care of another physician.

All claims are subject to payment edits and audit; medical records may be requested when an SRE or PPC is identified as preventable.

Providers must follow specified claim submission reporting rules for reporting-only (no-pay) claims and applicable billing formats (e.g., inpatient bill type 110 with reason code 11 and POA indicators; outpatient reporting and use of designated modifiers), when applicable for PPC/SRE reporting.

Enumerated event coverage nodes

Specific events enumerated in the policy and the Plan's coverage stance (examples extracted from the crosswalk).

Surgery or other invasive procedure performed on the wrong site — Not reimbursed (NCD = ✓; SRE = ✓).

Surgery or other invasive procedure performed on the wrong patient — Not reimbursed (NCD = ✓; SRE = ✓).

Wrong surgery or other invasive procedure performed on the patient — Not reimbursed (NCD = ✓; SRE = ✓).

Unintended retention of a foreign object after surgery — PPC HCAC = ✓; SRE = ✓ (Plan treats as an enumerated event).

Surgical site infection following specific procedures (e.g., cardiac implantable device, CABG including mediastinitis, certain orthopedic procedures, bariatric surgery) — PPC HCAC = ✓ (listed HCAC surgical site infections).

Relevant Codes and Modifiers

NCD-related surgical event diagnosis codesICD-10Not Covered

Y65.53	Performance of correct procedure (operation) on wrong side/body part
Y65.52	Performance of procedure (operation) on patient not scheduled for surgery
Y65.51	Performance of wrong procedure (operation) on correct patient

NCD-related surgical event modifiersModifierNot Covered

PA	Modifier = Surgery on wrong body part
PB	Modifier = Surgery on wrong patient
PC	Modifier = Wrong surgery on patient

Reference code listsICD-10

CMS HAC ICD-10 list

Reference to CMS Healthcare Acquired Conditions ICD-10 code list (see references)

Reporting, Billing, and Operational Requirements for Providers

Prior Authorization

SRE reporting submission — Submit SRE form via fax (medical events) within 7 and 30 calendar days; behavioral health SREs fax to Optum 844-814-5698

Providers must report Serious Reportable Events (SREs) to the Department of Public Health (DPH) by submitting a DPH Serious Incident Report Form within seven (7) calendar days and a follow-up within thirty (30) calendar days from the date the event occurred. The 30-day SRE report must include the root cause analysis, determination of preventability, and corrective actions when applicable. For medical SREs, submit the SRE form to Mass General Brigham Health Plan via fax at 617-526-1916 within the 7- and 30-day timeframes. For behavioral health SREs, submit the DPH 7/30-day SRE report to the behavioral health partner Optum via fax at 844-814-5698.

Submit DPH Serious Incident Report Form within 7 and 30 calendar days.
30-day report must include root cause analysis, preventability determination, and corrective measures.
Medical SRE fax to Mass General Brigham Health Plan: 617-526-1916.
Behavioral health SRE fax to Optum: 844-814-5698.

Key Terms

Serious Reportable Event (SRE) — definition and characteristics

DefinitionAn event that occurs on the premises of a provider's site that results in an adverse patient outcome; is clearly identifiable and measurable; usually or reasonably preventable; and is significantly influenced by provider policies and procedures (Mass General Brigham Health Plan uses the NQF definition and designation by DPH/EOHHS).

Key characteristicsOccurs on provider premises; identifiable and measurable; usually or reasonably preventable; risk influenced by provider policies/procedures.

DesignationDesignated as an SRE by the Department of Public Health (DPH) and identified by EOHHS.

Relation to other termsUsed alongside Provider Preventable Conditions (PPCs) and mapped to CMS/state reportable event frameworks in the policy crosswalk.

Provider Preventable Condition (PPC) — CMS-aligned definition

Policy Summary

PayerMass General Brigham Health Plan

PolicyProvider Reporting and Reimbursement for SREs, PPCs, and SADEs

Policy CodePolicy N/A

Change TypeAnnual review / clerical updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit SRE form via fax for medical events within 7 days and the 30-day report including RCA as required.

SourceLink

On This Page

Patient death or serious injury associated with contaminated drugs, devices, or biologics provided by the healthcare setting — PPC OPPC = ✓; SRE = ✓.

Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting — PPC HCAC = ✓; SRE = ✓.

Patient suicide or attempted suicide while being cared for in a health care facility — PPC OPPC = ✓; SRE = ✓.

Deep vein thrombosis/pulmonary embolism following certain orthopedic procedures (total knee replacement, hip replacement) — PPC HCAC = ✓ (note: does not apply to pediatric or obstetric patients).

Iatrogenic pneumothorax with venous catheterization — PPC HCAC = ✓.

Stage III/IV and unstageable pressure ulcers — PPC HCAC = ✓; PPC OPPC = ✓; SRE = ✓.

Medication errors causing death or serious injury (wrong drug, dose, patient, time, rate, preparation, route) — PPC OPPC = ✓; SRE = ✓.

Maternal or neonatal death or serious injury in low-risk cases associated with labor/delivery — PPC OPPC = ✓; SRE = ✓.

Failure to follow up or communicate laboratory, pathology, or radiology test results leading to patient death or serious injury — PPC OPPC = ✓; SRE = ✓.

Patient fall resulting in death or serious injury while in care — PPC HCAC = ✓; SRE = ✓.

Environmental and equipment hazards (electric shock, wrong gas delivery, burns, physical restraints harm) — various PPC/SRE designations; many listed as SRE = ✓.

Introduction of a metallic object into an MRI area causing death or serious injury — PPC OPPC = ✓; SRE = ✓.

Potentially criminal events (impersonation of licensed personnel, abduction, sexual abuse/assault, physical assault resulting in death/serious injury) — SRE = ✓ (enumerated as reportable).

Billing Rule

PPC claim and SRE dual-reporting — Report PPCs via claims submission per ACA/42 CFR; if PPC also SRE, notify Plan and report to DPH and submit 7-day/30-day reports

If an event qualifies as both a Preventable Patient Care (PPC) event and an SRE as designated by DPH (see applicable regulatory lists), providers must report the PPC through claims submission per Section 2702 of the ACA and 42 CFR.447.26, and must also notify Mass General Brigham Health Plan (medical events) or Optum (behavioral health events). In addition to the claims-based PPC reporting, the provider must report the occurrence as an SRE to DPH and submit the documented 7- and 30-day SRE reports to the Plan or Optum as described above.

Report PPCs via claims submission per ACA Section 2702 and 42 CFR.447.26.
If PPC is also an SRE, notify Plan (medical) or Optum (BH) and report to DPH.
Submit documented 7-day and 30-day SRE reports to Mass General Brigham Health Plan (medical) or Optum (behavioral health).

Billing Rule

Claim submission billing modifiers and POA reporting — Use specified bill types, reason code 11, POA indicators and modifiers PA/PB/PC for outpatient/NCD scenarios

Billing and coding for services directly related to PPCs/SREs must follow specific claim types, reason codes, modifiers, and Present on Admission (POA) reporting rules: Inpatient hospitals should submit a no-pay claim on bill type 110 with reason code 11 and include the appropriate POA indicator for reporting only (Y/N/U/W/1 or blank as defined by POA guidance). Outpatient providers and freestanding ambulatory surgery centers should submit a no-pay claim on bill type 130 with reason code 11 and use the modifier values PA (wrong body part), PB (wrong patient), or PC (wrong procedure on patient) for reporting purposes only. All other providers must submit a separate professional claim to identify non-covered device (NCD)-related services using the applicable NCD modifier and Reason code 11; when applicable use diagnosis codes Y65.53 (wrong body part), Y65.52 (wrong patient), or Y65.51 (wrong procedure) with the corresponding modifiers PA/PB/PC. If non-NCD-related services are performed, submit a second professional claim to bill for those services.

Inpatient: no-pay claim on bill type 110, Reason Code 11, include POA indicator (Y/N/U/W/1 or blank) for reporting only.
Outpatient/ASC: no-pay claim on bill type 130, Reason Code 11, use modifiers PA (wrong body part), PB (wrong patient), PC (wrong surgery) for reporting only.
All other providers: submit separate professional claim with applicable NCD modifier and Reason Code 11.
Use diagnosis codes Y65.53, Y65.52, Y65.51 with corresponding modifiers PA/PB/PC when applicable.
If non-NCD-related services provided, submit a second professional claim to bill for those services.

Documentation Required

Provider reporting and claims conditions — Providers must follow reporting mechanisms and regulatory timeframes; claims payment subject to eligibility and coordination

Providers must comply with all applicable state and federal SRE/PPC reporting regulations and adhere to the regulatory timeframes and mechanisms described above. Claims payment is subject to member eligibility, benefits, coordination of benefits, referral/authorization/notification and utilization management rules, adherence to plan policies, claims editing logic, and provider contract terms. In case of conflict between these payment guidelines and a provider's agreement, the provider contract governs. Payment processing is guided by contract terms, member benefit scope, clinical rationale, industry standard code edits, and coding conventions.

Follow state and federal SRE/PPC regulations (including neighboring states when applicable).
Claims are subject to eligibility, benefits, COB, authorizations, utilization management, plan policies, claims edits, and provider contract.
Provider contract terms prevail if in conflict with these payment guidelines.

DefinitionUmbrella term for conditions that meet CMS definitions of 'health care-acquired condition' (HCAC) or 'other provider preventable condition' (OPPC) per 42 CFR 447.26(b).

HCAC criteriaConditions that are high cost or high volume, lead to assignment to a higher-paying DRG when present as a secondary diagnosis, and could reasonably have been prevented through evidence-based guidelines.

NCD (mandatory OPPC) examplesWrong surgical or invasive procedure on a patient, wrong body part, or wrong patient — considered NCDs under 42 CFR 447.26(b).

ScopePPCs may occur in any health-care setting and include state-defined additional OPPCs that meet federal criteria.

Serious Adverse Drug Event (SADE) — preventable drug-related events

DefinitionAny untoward, preventable medical occurrence associated with the use of a controlled substance in humans that results in death, a life‑threatening outcome, inpatient hospitalization or prolongation of hospitalization, persistent or significant incapacity, or a congenital anomaly; defined per M.G.L. c. 94C §1 and 105 CMR 130.332.

Outcomes includedDeath; life‑threatening outcome; inpatient hospitalization or prolonged hospitalization; persistent/significant incapacity or disruption of normal life functions; congenital anomaly or birth defect.

PreventabilityCharacterized as a preventable occurrence associated with controlled substance use.

SADE — historical note / prior update inclusion

Historical additionSADE definition was added to the policy in a prior update (publication history notes the addition in policy revisions).

Publication history referencePolicy publication history lists updates across 2009–2020 and notes: 'Updated Policy Definitions Section: Added Serious Adverse Drug Event (SADE) definition.'

Revision contextSADE was incorporated alongside additions to provider reporting requirements and SRE/PPC crosswalk updates in past revisions.

PPC / SRE — enumerated categories

Surgical eventsIncludes wrong site, wrong patient, wrong procedure and other surgical/invasive procedure errors — identified as NCD/PPC/NQF/SRE categories in the crosswalk.

Product/device eventsPatient death or serious injury associated with contaminated drugs/devices/biologics or device use/function other than intended (listed as SR E = yes).

Patient protection eventsEvents such as patient suicide/attempted suicide while in care and inappropriate discharge/release to unauthorized persons are listed under patient protection and as SR E where applicable.

Environmental/radiologic and criminal eventsIncludes environmental hazards, radiologic events, introduction of metallic objects into MRI zones, electric shock, wrong gas delivery, burns, restraints harm, and potentially criminal events (impersonation, abduction, sexual assault) — many classified as SR E = yes.