Md. Code Regs. 10.09.92.01

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.92.01 - Definitions

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

B. Terms Defined.

(1) "Acute hospital" means an institution that provides active, short-term medical diagnosis, treatment, and care.

(2) ''Acute level of care" means care in which a patient is treated:

(a) For a brief but severe episode of illness, for conditions that are the result of disease or trauma; and

(b) During recovery from surgery.

(3) ''Acute rehabilitation hospital" means an institution devoted to therapy that is designed to facilitate the process of recovery from illness or injury for patients with various neurological, muscular-skeletal, orthopedic, and other medical conditions following stabilization of acute medical issues.

(4) "Administrative day" means a day of medical services delivered to a participant who no longer requires an acute level of care.

(5) "Administrative services organization (ASO)" means an organization with which the Department contracts to assist in the management and operation of the Maryland Public Behavioral Health System.

(6) "Admission" means the formal acceptance by a hospital of a participant who is to be provided with room, board, and medically necessary services in an area of the hospital where patients stay at least overnight.

(7) "Ancillary services" means diagnostic and therapeutic services, including but not limited to radiology, laboratory tests, pharmacy, and physical therapy services, provided exclusive of room and board.

(8) "Concurrent review" means a periodic reauthorization of continued medical eligibility for the level of services provided in an acute hospital which allows for close monitoring of the participant's progress, treatment goals, and objectives during an inpatient hospitalization.

(9) "Date of service" means:

(a) For inpatient hospitalizations, the date of admission into an acute hospital up to, but not including, the date of discharge;

(b) For outpatient services, the date services are rendered in the outpatient department of the hospital;

(c) For emergency services, the date or dates the services are rendered in the emergency department of an acute hospital; or

(d) For observation services, the date or dates the services are rendered in an acute hospital.

(10) "Department" means the Maryland Department of Health and Mental Hygiene, which is the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq.

(11) "Designee" means any entity designated to act on behalf of the Department.

(12) "Diagnosis-related group" means a participant classification system adopted by the U.S. Department of Health and Human Services, in which each hospital discharge case is assigned a category based on the primary diagnosis, secondary diagnoses (if any), procedures performed, age, sex, and discharge status of the participant.

(13) "Electronic signature" means a secure electronic identification of an individual who authorizes an electronic record or transaction.

(14) "Emergency department" means the area in a hospital that is designed, staffed, and equipped to provide prompt treatment to individuals requiring immediate medical care for acute illness, trauma, and other medical conditions.

(15) "Emergency services" means any health care service provided to evaluate and treat any medical condition where immediate, unscheduled medical care is required.

(16) "Emergent condition" means a disease, illness, or injury characterized by sudden onset and symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in:

(a) Placing the participant's health or, with respect to a pregnant woman, the health of the woman or unborn child in serious jeopardy;

(b) Serious impairment of bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

(17) "Freestanding medical facility" means a facility:

(a) In which medical and health services are provided;

(b) That is physically separate from a hospital or hospital grounds; and

(c) That is an administrative part of a hospital or related institution.

(18) "Health Services Cost Review Commission (HSCRC)" means the independent organization within the Department of Health and Mental Hygiene which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.

(19) "Maryland Medical Assistance Program" means the program of comprehensive medical and other health-related care for indigent and medically indigent individuals.

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

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

(b) Consistent with 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 participant, family, or provider.

(21) "Medicare" means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq.

(22) "Nonqualified alien" means a foreign-born resident who:

(a) Is not a naturalized U.S. citizen; and

(b) Is eligible for federal Medical Assistance coverage of only emergency medical services, as specified under COMAR 10.09.24.05-2A.

(23) "Observation services" means the medically necessary services used to assess the participant's outpatient condition to determine the need for possible admission to an inpatient acute care setting.

(24) "Organ" means a part of an organism that is typically self-contained and has a specific vital function, such as a heart or liver.

(25) "Out-of-State hospital" means any hospital outside of Maryland, except for hospitals located in the District of Columbia.

(26) "Outpatient services" means nonemergency services provided to the participant on the hospital campus that do not require hospital admission.

(27) "Participant" means an individual who is enrolled with the Department to receive Medical Assistance services.

(28) "Patient" means an individual awaiting or undergoing health care or treatment.

(29) "Preauthorization" means the approval required from the Department or its designee before a service can be rendered by the provider and reimbursed.

(30) "Preoperative day" means an inpatient day in an acute hospital before:

(a) Surgery for a participant who is being admitted for surgery; or

(b) A surgical procedure when the participant was admitted for a nonsurgical procedure but the need for surgery arose during that stay.

(31) "Program" means the Maryland Medical Assistance Program.

(32) "Prospective payment system" means a predetermined amount of reimbursement per day for inpatient hospital services.

(33) "Provider" means an acute hospital which, through agreement with the Department, has been identified as a Program provider by the issuance of a provider number.

(34) "Retrospective review" means the process of determining medical necessity of an inpatient admission after the participant has been discharged from the hospital.

(35) "Specialty behavioral health" means services as defined in COMAR 10.09.70.02D and F.

Md. Code Regs. 10.09.92.01

Regulation .01 adopted effective 44:7 Md. R. 354, eff. 4/10/2017