Md. Code Regs. 10.09.94.01

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

Section 10.09.94.01 - Definitions

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

B. Terms Defined.

(1) "Acute hospital" means an institution that provides active, short-term medical diagnosis, treatment, and care.

(2) "Administrative day" means a day of medical services delivered to a participant who no longer requires the level of care that the provider is licensed to deliver.

(3) "Admission" means the formal acceptance by a hospital of a participant who is to be provided with room, board, and medically necessary services in an area of the hospital where patients stay at least overnight.

(4) "Ancillary services" means diagnostic and therapeutic services including but not limited to radiology, laboratory tests, pharmacy, and physical therapy services, provided exclusive of room and board.

(5) "Appropriate facility" means:

(a) A facility located within a 25-mile radius of the participant's residence; or

(b) If acceptable to the participant, a more distant facility, which is licensed and certified to render the participant's required level of care, except when the only facility or facilities that provide the level of care and specialized services required by the participant exceed that distance.

(6) "Concurrent review" means a periodic reauthorization of continued medical eligibility for the level of services provided by a special pediatric hospital, which allows for close monitoring of the participant's progress, treatment goals, and objectives, performed during an inpatient hospitalization.

(7) "Date of service" means:

(a) For inpatient hospitalizations, the date of admission into a special pediatric hospital up to, but not including, the date of discharge; or

(b) For outpatient services, the date services are rendered in the outpatient department of the hospital.

(8) "Department" means the Maryland Department of Health and Mental Hygiene, which is the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq.

(9) "Designee" means any entity designated to act on behalf of the Department.

(10) "Diagnosis-related group" means a participant classification system adopted by the U.S. Department of Health and Human Services, in which each hospital discharge case is assigned a category based on the primary diagnosis, secondary diagnoses, if any, procedures performed, and age, sex, and discharge status of the participant.

(11) "Electronic signature" means a secure electronic identification of an individual who authorizes an electronic record or transaction.

(12) "Health Services Cost Review Commission (HSCRC)" means the independent organization within the Department of Health and Mental Hygiene which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.

(13) "Level of care" means an assessment that an individual needs the level of services provided in a special psychiatric hospital.

(14) "Maryland Medical Assistance Program" means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.

(15) "Medically necessary" means that the service or benefit is:

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

(b) Consistent with 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 participant, family, or provider.

(16) "Medicare" means the medical insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq.

(17) "Out-of-State hospital" means any hospital outside of Maryland, except for hospitals located in the District of Columbia.

(18) "Outpatient services" means services provided to the participant on the hospital campus that do not require hospital admission.

(19) "Participant" means an individual who is enrolled with the Department to receive Medical Assistance services.

(20) "Plan of treatment" means a written plan developed by a participant's consulting physician and other appropriate clinicians, which is provided to the Department on request and includes:

(a) Diagnosis;

(b) Treatment goals;

(c) Specific procedures planned for the participant, including surgeries;

(d) Duration of treatment of each type of service ordered;

(e) Expected length of stay; and

(f) Any other appropriate information, including caregiver education and discharge plan.

(21) "Program" means the Maryland Medical Assistance Program.

(22) "Prospective payment system" means a predetermined amount of reimbursement per day for inpatient hospital services.

(23) "Provider" means a special pediatric hospital which, through agreement with the Department, has been identified as a Program provider by the issuance of a provider number.

(24) Special Pediatric Hospital.

(a) "Special pediatric hospital" means a facility licensed by the Office of Health Care Quality as a special hospital that provides nonacute medical, rehabilitation, therapy, and palliative services to children and adolescents younger than 22 years old.

(b) "Special pediatric hospital" includes an out-of-State or District of Columbia hospital identified by the Program as:

(i) A facility that provides nonacute medical, rehabilitation, therapy, and palliative services to children and adolescents younger than 22 years old; and

(ii) A facility that provides nonacute medical, rehabilitation, and therapy services to individuals ages 2 through 22 with co-occurring medical and behavioral conditions.

Md. Code Regs. 10.09.94.01

Regulation .01 adopted effective 44:7 Md. R. 354, eff. 4/10/2017