Md. Code Regs. 31.10.11.02

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

Section 31.10.11.02 - Definitions

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

B. Terms Defined.

(1) "Applicable standard code set" means the most recent versions, as of the date of service, of the following:

(a) For services rendered by health care practitioners, the Current Procedural Terminology (CPT) maintained and distributed by the American Medical Association, including its codes and modifiers, and codes for anesthesia services;

(b) For dental services, the Current Dental Terminology (CDT) maintained and distributed by the American Dental Association;

(c) For all professional and hospital services, the International Classification of Diseases, Clinical Modification (ICD-9 CM);

(d) For other health-related services, including prescribed drugs covered under a medical benefit of a contract issued by a third-party payor, the Centers for Medicare and Medicaid Services Common Procedure Coding System (HCPCS) levels I and II and modifiers maintained and distributed by the U.S. Department of Health and Human Services;

(e) For prescribed drugs covered under a pharmacy benefit of a contract issued by a third-party payor, the National Drug Codes (NDC) maintained and distributed by the U.S. Department of Health and Human Services;

(f) For anesthesia services, the codes maintained and distributed by the American Society of Anesthesiologists;

(g) For psychiatric services, the DSM-IV codes distributed by the American Psychiatric Association;

(h) For hospital and other applicable health-care services, including home health services, the State UB-92, Uniform Billing Data Elements Specification Manual;

(i) For hospital services pursuant to a Maryland contract or insurance policy, a revenue code:

(i) Approved by the Health Services Cost Review Commission for a hospital located in the State, or

(ii) Of the National or State Uniform Billing Data Elements Specifications for a hospital not located in the State; and

(j) For services rendered pursuant to Health-General Article, §15-103(b)(2), Annotated Code of Maryland, a code established by the Medicaid Program.

(2) "Auto code" means an ICD-9 code designed by a third-party payor as a diagnosis that is an emergency service.

(3) "CDT-1 Codes" means the current dental terminology, and its successors, required by the American Dental Association.

(4) "Clean claim" means a claim for reimbursement submitted to a third-party payor by a health care practitioner, pharmacy or pharmacist, hospital, or person entitled to reimbursement, that contains:

(a) In the case of a health care practitioner or person entitled to reimbursement:

(i) The data elements required by Regulation .08 of this chapter, and

(ii) Any attachments requested by the third-party payor pursuant to Regulation .10 of this chapter;

(b) In the case of a hospital or person entitled to reimbursement;

(i) The data elements required by Regulation .09 of this chapter, and

(ii) Any attachments requested by the third-party payor pursuant to Regulation .10 of this chapter; or

(c) In the case of a pharmacy or pharmacist, the data elements set forth on the Universal Prescription Drug Claim Form or its electronic equivalent.

(5) "CMS" means the federal Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.

(6) "CPT-4 Codes" means the Current Procedural Terminology published by the American Medical Association.

(7) "Emergency services" has the meaning stated in Health-General Article, §19-701(d), Annotated Code of Maryland.

(8) "Global contract" means an agreement between a third-party payor, and a health care practitioner, hospital, or person entitled to reimbursement in which:

(a) For billing and payment purposes:

(i) The services of one or more health care practitioners, hospitals, or persons entitled to reimbursement are bundled together; and

(ii) The third-party payor agrees to pay, and the health care practitioner, hospital, or person entitled to reimbursement, agrees to accept a single rate for the applicable technical, facility, ancillary, and professional components of the services specified in the agreement; or

(b) The third-party payor agrees to pay, and the health care practitioner, hospital, or person entitled to reimbursement, agrees to accept a daily or per diem rate for the services related to home infusion therapy.

(9) HCFA Form 1500.

(a) "HCFA Form 1500" means the health insurance claims form and its electronic successor or equivalent published by CMS for use by health care practitioners or persons entitled to reimbursement.

(b) "HCFA Form 1500" includes any successor to HCFA Form 1500 published by CMS.

(10) HCFA Form UB-92.

(a) "HCFA Form UB-92" means the Revenue Code Summary UB-92 health insurance claim form and its electronic successor or equivalent published by CMS for use by hospitals, or person entitled to reimbursement.

(b) "HCFA Form UB-92" includes any successor to HCFA Form UB-92 published by the CMS.

(11) "HCPCS" means CMS's current Healthcare Common Procedural Coding System.

(12) Health Care Practitioner.

(a) "Health care practitioner" means a physician or any other person licensed or certified under Health Occupations Article, Annotated Code of Maryland.

(b) "Health care practitioner" does not include a physician or other person licensed or certified under Health Occupations Article, Annotated Code of Maryland, who:

(i) Is compensated by a health maintenance organization on a salaried or capitated basis; or

(ii) Is rendering care to a member or subscriber of the health maintenance organization on a salaried or capitated system basis.

(13) "Hospital" means a hospital as defined in Health-General Article, §19-301(g), Annotated Code of Maryland.

(14) ICD 9-CM Codes.

(a) "ICD-9-CM Codes" means the current disease and procedure codes in the international classification of diseases published by the U.S. Department of Health and Human Services.

(b) "ICD-9-CM Codes" includes any successor to ICD-9-CM Codes published by the U.S. Department of Health and Human Services.

(15) "J512 Form" means the uniform dental claim form approved by the American Dental Association for use by dentists and its electronic successor or equivalent.

(16) Member.

(a) "Member" means an individual entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by a carrier.

(b) "Member" includes a subscriber or an insured.

(17) "Modifier" means a code that is appended to a CPT or HCPCS code to provide more specific information about a medical procedure.

(18) "Person entitled to reimbursement" means:

(a) A health care practitioner as defined in §B(12) of this regulation; or

(b) Any other person who furnishes health care services or supplies.

(19) "Primary care" has the meaning stated in COMAR 31.11.06.02B(49).

(20) "Primary payor" means a third-party payor that, pursuant to the terms of an insurance policy or contract, is required to provide coverage for benefits to the insured or member:

(a) Before any other third-party payor provides benefits; and

(b) Regardless of whether benefits are available under any other insurance policy or contract.

(21) "Secondary payor" means a third-party payor that, pursuant to the terms of an insurance policy or contract, is required to pay all or some portion of the difference between the total amount of a claim and the amount paid by the primary payor, subject to the limitations of the insurance policy or contract.

(22) "Third-party payor" 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) A health insurer or nonprofit health service plan authorized to offer health insurance policies or contracts in this State in accordance with the Insurance Article, Annotated Code of Maryland; or

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

(d) An MCO.

(23) "Universal Prescription Drug Claim Form" means the uniform prescription drug claim form developed by the National Council for Prescription Drug Programs, Inc. and its electronic successor or equivalent.

Md. Code Regs. 31.10.11.02

Regulations .02 adopted as an emergency provision effective July 22, 1993 (20:16 Md. R. 1274); adopted permanently effective October 25, 1993 (20:21 Md. R. 1653)
Regulation .02 amended effective 42:15 Md. R. 1019, eff.10/1/2015