Md. Code Regs. 31.10.51.03

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

Section 31.10.51.03 - Definitions

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

B. Terms Defined.

(1) "Analysis report" means the report required by Insurance Article, § 15-144(c), Annotated Code of Maryland.

(2) "As written " means the written policies, procedures, and related documents, including medical necessity criteria or guidelines, used in the development and description of a NQTL and the decision whether to apply a NQTL to a particular benefit by the carrier or any entity delegated by the carrier to manage mental health, substance use disorder, or medical/surgical benefits on behalf of the carrier.

(3) "Data report" means the report required by Insurance Article, § 15-144(f), Annotated Code of Maryland.

(4) "Evidentiary standards" means the carrier's defined level and type of evidence necessary to evaluate whether a given factor is established, present, or utilized, which results in the determination to apply or not apply a NQTL to which that factor relates.

(5) "Factor" means a circumstance, condition, fact, standard, criterion, influence, or any other consideration that contributes to the development, design, or implementation of a NQTL.

(6) "In operation" means as used in the implementation and application of NQTLs, including the administration of benefits.

(7) "Medical/surgical benefits" has the meaning stated in Insurance Article, § 15-144(a)(4), Annotated Code of Maryland, and may be abbreviated as "med/surg benefits " or "M/S benefits ".

(8) "Medical Necessity" means medical necessity as determined by the definition, criteria, or guidelines used by the carrier or its private review agent to determine what is necessary, efficient, or appropriate for purposes of coverage of a service or benefit. Insurance Article, § 15-802, Annotated Code of Maryland, requires use of the criteria published by the American Society of Addiction Medicine for the evaluation of the medical necessity, efficiency, or appropriateness of services to treat a substance use disorder.

(9) "Mental health benefits" has the meaning stated in Insurance Article, § 15-144(a)(5), Annotated Code of Maryland.

(10) "MH/SUD" means mental health benefits and substance use disorder benefits as a combined category.

(11) "NQTL" means a nonquantitative treatment limitation as defined in Insurance Article, § 15-144(a)(6), Annotated Code of Maryland.

(12) "Parity Act" has the meaning stated in Insurance Article, § 15-144(a)(7), Annotated Code of Maryland.

(13) "Parity Act classification" has the meaning stated in Insurance Article, § 15-144(a)(8), Annotated Code of Maryland.

(14) "Process" means a series of actions or steps taken during the development, design, or implementation/application of a NQTL.

(15) "Provider" means:

(a) A physician;

(b) Hospital;

(c) Facility;

(d) Practitioner; or

(e) Other person who is licensed or otherwise authorized to provide healthcare services.

(16) "Source" means the data, analyses, recommendation, requirement, meeting, or other information upon which a factor is based or from which a factor is derived or arises.

(17) "Substance use disorder benefits " has the meaning stated in Insurance Article, § 15-144(a)(9), Annotated Code of Maryland.

(18) "Summary form" means the form required by Insurance Article, § 15-144(g)(5), Annotated Code of Maryland.

Md. Code Regs. 31.10.51.03

Regulations .03 adopted effective 48:26 Md. 1113, eff. 12/27/2021