Md. Code Regs. 10.25.07.02

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

Section 10.25.07.02 - Definitions

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

B. Terms Defined.

(1) "Adjudication of claims" means the activities necessary for the adjudication or subrogation of a health benefit claim that has been filed or may be filed by a patient, or with the authorization of a patient on the patient's behalf, including:

(a) Determinations of eligibility or coverage, including coordination of benefits or the determination of cost-sharing amounts;

(b) Reasonable prospective, concurrent, or retrospective utilization review or predetermination of benefit coverage;

(c) Review, audit, and investigation of a specific claim for payment of benefits with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges;

(d) Billing, claims management, collection activities, obtaining payment under a contract for reinsurance, and related health care data processing; and

(e) Risk adjustments based on enrollee health status and demographic characteristics.

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

(3) "Disclose" or "disclosure" means the release, redisclosure, transfer, provision, access, transmission, communication, or divulgence in any other manner of health information, including an acknowledgement that a health record on a particular patient or recipient exists outside the entity holding the information.

(4) "Electronic health care transactions" means health care transactions that have been approved by a nationally recognized health care standards development organization (SDO) to support health care informatics, information exchange, systems integration, and other health care applications.

(5) "Electronic Health Network (EHN)" means an entity involved in the exchange of electronic health care transactions between electronic health networks, payors, providers, vendors, or other entities.

(6) "Entity" means a partnership, firm, association, limited liability company, limited liability partnership, or a public or private corporation.

(7) "Grievance" means a written complaint or other information received by the Commission indicating that an MHCC-certified EHN may have violated one of the provisions of Regulation .09 of this chapter.

(8) "Health information" means any information, whether oral or recorded in any form or medium, including electronic health information, that:

(a) Is created or received by a health care provider, health plan, public health authority, employer, life insurer, or health care clearinghouse; and

(b) Relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual.

(9) "Legally protected health information" means the health information with a date of service after May 31, 2022, that is subject to restrictions under Health-General Article, §4-302.5, Annotated Code of Maryland, and COMAR 10.11.08, including:

(a) Mifepristone data, as defined by the Secretary; and

(b) As specified by the Secretary, the diagnosis, procedure, medication, and other codes related to:

(i) Abortion care; and

(ii) Sensitive health services, as defined by Health-General, §4-301, Annotated Code of Maryland.

(10) Medical Care Electronic Claims Clearinghouse.

(a) "Medical care electronic claims clearinghouse" is an entity that transmits electronic health care transactions.

(b) "Medical care electronic claims clearinghouse" includes an electronic health network.

(11) "MHCC" means the Maryland Health Care Commission.

(12) "MHCC-Certified Electronic Health Network" means an entity that has received certification from the Maryland Health Care Commission.

(13) "Payor" means an entity that administers or provides reimbursement for health care benefits on an expense-incurred basis, including:

(a) A health maintenance organization issued a certificate of authority in accordance with Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland;

(b) A health insurer or nonprofit health service plan authorized to offer health insurance policies or contracts in this State in accordance with Insurance Article, Title 14, Annotated Code of Maryland;

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

(d) An entity that subcontracts with a third-party payor to provide specialty health care services including, but not limited to, a dental benefit payor, a vision benefit payor, a mental health benefit payor, and a pharmacy benefit manager; or

(e) A managed care organization that contracts with the Maryland Medical Assistance program to provide health services to Maryland Medical Assistance recipients in accordance with Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland.

(14) "Qualified accreditation or certification organization" means a nationally recognized entity that has established privacy and security standards for electronic health networks and accredits or certifies networks that meet those standards.

Md. Code Regs. 10.25.07.02

Regulation .02 amended effective April 3, 2000 (27:6 Md. R. 641)
Regulations .02 adopted effective March 24, 2008 (35:6 Md. R. 698)
Regulation .02B amended effective December 15, 2008 (35:25 Md. R. 2150); amended effective 51:3 Md. R. 152, eff. 1/11/2024, exp. 7/9/2024(Emergency); amended effective 51:9 Md. R. 440, eff. 5/13/2024.