Md. Code Regs. 10.25.09.02

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

Section 10.25.09.02 - Definitions

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

B. Terms Defined.

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

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

(3) "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, P.L. No. 104-191, 42 U.S.C. Title XI, Part C.

(4) "Deputy Director" means the Deputy Director for Data Systems and Analysis at the Maryland Health Care Commission, or the Deputy Director's designee.

(5) "Designate" means to select and to enter into a written agreement with.

(6) "Designated EHNs" means MHCC-certified EHNs that have been selected by a payer to submit electronic health care transactions under a written service agreement with the payer on behalf of health care practitioners.

(7) Electronic health care transactions" means health care transactions that are defined under HIPAA Transaction and Code Set Standards.

(8) "Electronic health network (EHN)" means an entity that processes or facilitates processing of electronic transactions in standard or nonstandard formats, between two or more trading partners in the health care community.

(9) "MHCC-certified electronic health network" means an entity that has received certifications from the Maryland Health Care Commission.

(10) "Health insurance claim" means a submission of a claim to a third-party payer for payment for services rendered by a health care practitioner in Maryland.

(11) "Third-party payer" or "payer" means a person 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) 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) Third-party administrator registered under Insurance Article, Title 14, Annotated Code of Maryland;

(d) Specialty payers, such as Pharmacy Benefit Managers (PBMs); or

(e) Managed Care Organizations (MCOs) which contract with Maryland Medicaid to provide health services to Medicaid enrollees.

Md. Code Regs. 10.25.09.02

Regulation .02 amended effective July 23, 2001 (28:14 Md. R. 1322)