Md. Code Regs. 10.09.12.01

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.12.01 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Customary charge" means the uniform amount that the provider charges in the majority of cases for a specific supply or piece of equipment, excluding token charges for charity patients and substandard charges for welfare and other low income patients.

(2) "Customized equipment" means durable medical equipment which is uniquely constructed or substantially modified by the provider from the standard product:

(a) For a specific recipient according to the description and orders of a physician; and

(b) In such a way that the equipment can only be used by the specific recipient.

(3) "Department" means Department as defined in COMAR 10.09.36.01A.

(4) "Disposable medical supplies" means consumable or disposable items with minimal or no potential for reuse which are used to serve a medically necessary purpose and, with the exception of disposable gloves and incontinence supplies, have no practical use in the absence of illness, injury, disability, or health condition.

(5) "Durable medical equipment" means equipment which satisfies all of the following requirements:

(a) It can withstand repeated use;

(b) It is used to serve a medically necessary purpose; and

(c) It has no practical use in the absence of illness, injury, disability, or health condition.

(6) "Home" means that place of residence occupied by the recipient, including an assisted living facility, but other than a hospital, nursing facility, or other medical institution.

(7) "Hospital" means an institution which falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.01 or other applicable standards established by the state in which the service is provided.

(8) "Incontinence" means the inability to refrain from yielding to the urge to urinate or defecate for persons previously having bowel or bladder control or individuals who are lacking bowel or bladder control due to congenital anomalies or postnatal insult.

(9) "Invoice" means a form designated by the Department for use by providers in submitting bills for payment.

(10) "Maximum allowable reimbursement" means the payment limitation established by the Department.

(11) "Medical Assistance Program" means the Medical Assistance Program as defined in COMAR 10.09.36.01A.

(12) "Medically necessary" means that the service or benefit is:

(a) Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;

(b) Consistent with current accepted standards of good medical practice;

(c) The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and

(d) Not primarily for the convenience of the consumer, family, or provider.

(13) "Medicare" means Medicare as defined in COMAR 10.09.36.01A.

(14) "Nursing facility" means a facility licensed as a comprehensive care or extended care facility pursuant to COMAR 10.07.02.

(15) "Physical therapy program" means an established program that outlines the prescribed equipment and treatment, along with frequency, duration, and goals or expected outcome of the recipient.

(16) "Prepayment authorization" means the approval required from the Department or its designee before services can be reimbursed.

(17) "Prescriber" means a physician, dentist, podiatrist, physician's assistant, clinical nurse specialist, or nurse practitioner licensed in the state in which the prescriber's practice is maintained who has examined the recipient.

(18) "Prescriber order" means a document on the prescriber's letterhead or prescription form which details the:

(a) Patient name and Medical Assistance number;

(b) Item needed including the accessories, adaptions, modifications, and attachments considered medically necessary and medically appropriate by the prescriber;

(c) Estimated quantity of the item;

(d) Length of time of need;

(e) Date of face-to-face encounter and how the health status of the recipient at the time of the face-to-face encounter is related to the items prescribed; and

(f) Prescriber's signature.

(19) "Prescription" means a written order for medical supplies or equipment, signed by the prescriber.

(20) "Program" means program as defined in COMAR 10.09.36.01A.

(21) "Provider" means provider as defined in COMAR 10.09.36.01A.

(22) "Recipient" means recipient as defined in COMAR 10.09.36.01A.

(23) Wholesale cost.

(a) "Wholesale cost" means the price paid by the provider to the manufacturer or any other supplier for disposable medical supplies or durable medical equipment after consideration of both primary discounts and secondary volume and prompt payment discounts applicable at the time the manufacturer's invoice is paid.

(b) "Wholesale cost" includes, but is not limited to:

(i) Shipping;

(ii) Handling; and

(iii) Insurance costs.

(c) "Wholesale cost" does not include associated costs such as:

(i) Evaluation;

(ii) Assembly by the provider;

(iii) Fitting and adjustment; and

(iv) Delivery to the recipient.

Md. Code Regs. 10.09.12.01

Regulation .01B amended effective July 11, 1988 (15:13 Md. R. 1553)
Regulation .01B amended effective September 29, 2003 (30:19 Md. R. 1331); August 1, 2005 (32:15 Md. R. 1320); September 11, 2006 (33:18 Md. R. 1505); April 30, 2012 (39:8 Md. R. 533)