Md. Code Regs. 10.25.06.02

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.25.06.02 - Definitions

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

B. Terms Defined.

(1) "Adjudicated" means paid, resolved, or settled.

(2) "Behavioral health care services" means procedures or services rendered by a health care practitioner for the treatment of mental health or substance use disorders.

(3) "Capitated encounter" means a health care visit in which a health care practitioner or office facility provides a service pursuant to an agreement with a reporting entity for reimbursement on an aggregate fixed sum or per capita basis.

(4) "Commission" means the Maryland Health Care Commission.

(5) "Crosswalk" means a list of all codes and their definitions in a separate file that maps to a specific data field.

(6) "Executive Director" means the Executive Director of the Maryland Health Care Commission.

(7) "Fee-for-service encounter" means a health care visit in which a health care practitioner or office facility provided a health care service for which a claim was submitted to a reporting entity for payment, and payment was made on a per service basis.

(8) "General health benefit plan" means:

(a) A hospital or health care policy, contract, or certificate issued by a payor as defined in this section;

(b) A behavioral health services plan;

(c) A pharmacy benefit management services plan;

(d) A vision plan certified by the Maryland Health Benefit Exchange; or

(e) A dental plan certified by the Maryland Health Benefit Exchange.

(9) "Health Benefit Exchange" or "Exchange" means the Maryland Health Benefit Exchange established as a public corporation under Insurance Article, § 31-102, Annotated Code of Maryland, and includes the Individual Exchange and the Small Business Health Operations Program (SHOP) Exchange.

(10) "Health care service" means a health or medical care procedure or service rendered by a health care practitioner that:

(a) Provides testing, diagnosis, or treatment of human disease or dysfunction; or

(b) Dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of human disease or dysfunction.

(11) "Health information exchange" or "HIE" means an entity that creates or maintains an infrastructure that provides organizational and technical capabilities in an interoperable system for the electronic exchange of protected health information among participating organizations not under common ownership, in a manner that ensures the secure exchange of protected health information to provide care to patients. An HIE does not include an entity that is acting solely as a health care clearinghouse, as defined in 45 CFR § 160.103. A payor may act as, operate, or own an HIE subject to these regulations.

(12) "HIPAA" means the U.S. Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as implemented and amended in federal regulations, including the HIPAA Privacy and Security rules, 45 CFR §§ 160 and 164, as may be amended, modified, or renumbered and including as amended by the Health Information Technology for Economic and Clinical Health (HITECH) Act.

(13) "Managed behavioral health care organization" means a company, organization, private review agent, or subsidiary that:

(a) Contracts with a payor as defined in this section to provide, undertake to arrange, or administer behavioral health care services to members; or

(b) Otherwise makes behavioral health care services available to members through contracts with health care providers.

(14) "Managed care organization" or "MCO" means:

(a) A certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments; or

(b) A corporation that:

(i) Is a managed care system that is authorized to receive medical assistance prepaid capitation payments;

(ii) Enrolls only program recipients or individuals or families served under the Maryland Children's Health Program; and

(iii) Is subject to the requirements of Health-General Article, §15-102.4, Annotated Code of Maryland.

(15) "Master Patient Index" means a database that maintains a unique index identifier for each patient whose protected health information may be accessible through the HIE and is used to cross reference patient identifiers across multiple participating organizations to allow for patient search, patient matching, and consolidation of duplicate records.

(16) "Medical Care Data Base" or "MCDB" means the data base established and maintained by the Commission pursuant to Health-General Article, § 19-133, Annotated Code of Maryland, that collects eligibility data, professional services claims, institutional services claims, pharmacy claims, and provider data for Maryland residents enrolled in private insurance, Medicaid, or Medicare. The MCDB is Maryland's All Payer Claims Data Base.

(17) "MCDB Submission Manual" or "Manual" means the composition of data reporting requirements with guidelines of technical specifications, layouts, and definitions necessary for filing the reports required by this chapter.

(18) "Non-Fee-for-Service Expenses Report" means a report with information on lump sum payments made by a reporting entity to providers as part of the reporting entity's compensation to the providers for non-claims-based services.

(19) "Office facility" means a freestanding facility providing:

(a) Ambulatory surgery;

(b) Radiologic or diagnostic imagery; or

(c) Laboratory services.

(20) "Payor" means:

(a) An insurer or nonprofit health service plan that holds a certificate of authority and provides health insurance policies or contracts in Maryland;

(b) A health maintenance organization (HMO) that holds a certificate of authority in Maryland; or

(c) For Medical Care Data Base purposes:

(i) A third-party administrator registered under Insurance Article, Title 8, Subtitle 3, Annotated Code of Maryland;

(ii) A managed behavioral health care organization as defined in this section; or

(iii) A pharmacy benefit manager.

(21) "Person" means an individual, receiver, trustee, guardian, personal representative, fiduciary, representative of any kind, partnership, firm, association, corporation, or other entity.

(22) "Pharmacy benefit management services" means:

(a) The procurement of prescription drugs at a negotiated rate for dispensation within the State to beneficiaries;

(b) The administration or management of prescription drug coverage provided by a purchaser for beneficiaries; and

(c) Any of the following services provided with regard to the administration of prescription drug coverage:

(i) Mail service pharmacy;

(ii) Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries;

(iii) Clinical formulary development and management services;

(iv) Rebate contracting and administration;

(v) Patient compliance, therapeutic intervention, and generic substitution programs; or

(vi) Disease management programs.

(d) "Pharmacy benefit management services" does not include any service provided by a nonprofit health maintenance organization that operates as a group model, provided that the service is provided solely to a member of the nonprofit health maintenance organization and is furnished through the internal pharmacy operations of the nonprofit health maintenance organization.

(23) "Pharmacy benefit manager" means a person who performs pharmacy benefit management services and is registered as a pharmacy benefit manager under Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland.

(24) "Practitioner" means a person who is licensed, certified, or otherwise authorized under Health Occupations Article, Annotated Code of Maryland, to provide health care services in the ordinary course of business or practice of a profession or in an approved education or training program.

(25) "Practitioner federal tax ID number" means the federal tax identification number of the practitioner, practice, supplier or office facility receiving reimbursement for the service provided.

(26) "Practitioner/supplier ID number" means the unique identification number used by the reporting entity to identify the particular practitioner or supplier.

(27) "Primary diagnosis" means the principal diagnosis for the health care service visit.

(28) "Provider" means:

(a) A practitioner;

(b) A facility where health care is provided to patients or recipients, including:

(i) A facility, as defined in Health-General Article, §10-101(e), Annotated Code of Maryland;

(ii) A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland;

(iii) A related institution, as defined in Health-General Article, §19-301, Annotated Code of Maryland;

(iv) A health maintenance organization, as defined in Health-General Article, §19-701(g), Annotated Code of Maryland;

(v) An outpatient clinic; and

(vi) A medical laboratory; or

(c) The agents and employees of a facility who are licensed or otherwise authorized to provide health care, the officers and directors of a facility, and the agents and employees of a health care provider who are licensed or otherwise authorized to provide health care.

(29) "Qualified dental plan" means a dental plan certified by the Maryland Health Benefit Exchange that provides limited scope dental benefits, as described in § 1311(c) of the Affordable Care Act and Insurance Article, § 31-115, Annotated Code of Maryland.

(30) "Qualified health plan" means a general health benefit plan that has been certified by the Maryland Health Benefit Exchange to meet the criteria for certification described in § 1311(c) of the Affordable Care Act and Insurance Article, § 31-115, Annotated Code of Maryland.

(31) "Qualified vision plan" means a vision plan certified by the Maryland Health Benefit Exchange that provides limited scope vision benefits, as described in the Insurance Article, § 31-108(b)(3), Annotated Code of Maryland.

(32) "Reporting entity" means a payor, third-party administrator, managed behavioral health care organization, or pharmacy benefit manager that is designated by the Commission to provide reports consistent with this chapter to be collected and compiled into the Medical Care Data Base.

(33) "State-designated health information exchange" or "State-designated HIE" means an HIE designated by the Maryland Health Care Commission and the Health Services Cost Review Commission pursuant to the statutory authority set forth in Health General Article, § 19-143, Annotated Code of Maryland.

(34) "Supplier" means a person or entity, including a health care practitioner, which supplies medical goods or services.

(35) "Third-party administrator" means a person that is registered as an administrator under Insurance Article, Title 8, Subtitle 3, Annotated Code of Maryland.

Md. Code Regs. 10.25.06.02

Regulations .02 adopted effective August 21, 2000 (27:16 Md. R. 1525)
Regulations .02 adopted effective April 19, 2010 (37:8 Md. R. 617)
Regulations .02 adopted as an emergency provision effective January 9, 2014 (41:3 Md. R. 200); adopted permanently effective 41:5 Md. R. 344, eff.3/17/2014
Regulation .02 amended effective October 18, 1999 (26:21 Md. R. 1629); amended effective 48:21 Md. R. 889, eff. 10/18/2021