Md. Code Regs. 10.67.13.02

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

Section 10.67.13.02 - Definitions

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

B. Terms Defined.

(1) "Adverse decision" means a review determination by a managed care organization that a health care service for which a provider seeks reimbursement is not medically necessary.

(2) "Affiliate" means a person who, directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with another person.

(3) "Case record" means documentation submitted to an independent review organization consisting of:

(a) A claim and only the supporting documentation, including medical records, originally submitted to a managed care organization by a provider prior to the managed care organization's adverse decision on the claim;

(b) The managed care organization's adverse decision; and

(c) The managed care organization's written rationale for the adverse decision.

(4) "Claim" means a clean claim as defined in COMAR 31.10.11.02.

(5) "Complaint" means an appeal of an adverse decision filed with the independent review organization.

(6) "Department" means the Maryland Department of Health and Mental Hygiene.

(7) "Expert reviewer" means a physician or other appropriate health care provider who contracts with the independent review organization to conduct a review of a managed care organization's adverse decision.

(8) "Health care service" means a health or medical care procedure or service rendered by a provider including:

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

(b) Dispensing of drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; or

(c) Any other care, service, or treatment of disease or injury, the correction of defects, or the maintenance of the physical and mental well-being of human beings.

(9) "Independent review organization" means an entity that contracts with the Department to conduct independent review of managed care organizations' adverse decisions.

(10) "Managed care organization (MCO)" has the meaning stated in Health-General Article, §15-101, Annotated Code of Maryland.

(11) "Medicaid" means the program administered by the State under Title XIX of the Social Security Act, which provides comprehensive medical and other health-related care for persons.

(12) "Medical record" has the meaning stated in Health-General Article, §4-301, Annotated Code of Maryland.

(13) "Medically necessary" means a health care service that is:

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

(b) Consistent with currently 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, the consumer's family, or the provider.

(14) "Provider" means any individual or entity that has a valid provider agreement with a Medicaid managed care organization or is a nonparticipating provider rendering covered Medicaid services to the managed care organization's enrollees.

Md. Code Regs. 10.67.13.02

Regulations .02 recodified from 10.09.86.02 effective 46:22 Md. R. 976, eff. 11/1/2019