Md. Code Regs. 10.09.95.01

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

Section 10.09.95.01 - Definitions

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

B. Terms Defined.

(1) "Administrative day" means a day of medical services delivered to a participant who no longer requires the level of care which the provider is licensed to deliver and is awaiting placement in a nursing home or residential care facility.

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

(3) "Ancillary services" means diagnostic and therapeutic services, provided exclusive of room and board, including but not limited to:

(a) Radiology;

(b) Laboratory tests;

(c) Pharmacy services; and

(d) Physical therapy services.

(4) "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.

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

(6) "Date of service" means:

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

(b) For outpatient services, the date services are rendered in the outpatient department of the special psychiatric hospital; and

(c) For observation services, the date or dates the services are rendered in a special psychiatric hospital, which are ordered by a medical staff practitioner to determine the need for inpatient admission.

(7) "Department" means the State 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.

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

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

(10) "Emergent condition" means a disease, illness, or injury characterized by sudden onset and symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in:

(a) Placing the participant's health or, with respect to a pregnant woman, the health of the woman or unborn child in serious jeopardy;

(b) Serious impairment of bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

(11) "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.

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

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

(14) "Medicaid" means the Maryland Medical Assistance Program.

(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) "Mental health services" means those services described in COMAR 10.09.59.06 rendered to treat the diagnoses set forth in COMAR 10.09.70.02.

(18) "Nonqualified alien" means a foreign-born resident who:

(a) Is not a naturalized U.S. citizen; and

(b) Is eligible for federal Medical Assistance coverage of only emergency medical services, as specified under COMAR 10.09.24.05-2A.

(19) "Observation services" means the medically necessary diagnostic services used to assess the participant's outpatient condition to determine the need for possible admission to an inpatient special psychiatric care setting.

(20) "Organ" means a part of an organism that is typically self-contained and has a specific vital function, such as a heart or liver.

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

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

(23) "Partial hospitalization" means outpatient, intensive, nonresidential psychiatric treatment, which is an alternative to inpatient acute general hospitalization, for any part of a 24-hour day for a minimum of 4 consecutive hours per day.

(24) "Participant" means a person who is certified as eligible for and is receiving Medical Assistance benefits.

(25) "Patient" means an individual awaiting or undergoing health care or treatment.

(26) "Plan of treatment" means a written plan, developed to address the referred problem or problems, which includes:

(a) Diagnosis;

(b) Treatment goals;

(c) Frequency of visits for each type of service ordered;

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

(e) Prognosis; and

(f) Other appropriate items.

(27) "Preauthorization" means the approval required from the Department or its designee before a service can be rendered by the provider and reimbursed.

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

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

(30) "Retrospective review" means the process of determining medical necessity of an inpatient admission after the participant has been discharged from the hospital.

(31) "Special psychiatric hospital" means an institution that:

(a) Provides short-term services for psychiatric illnesses in a hospital setting with facilities, medical staff, and all necessary personnel to provide diagnosis, care, and treatment;

(b) Falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland; and

(c) Is licensed pursuant to COMAR 10.07.01 or other applicable standards established by the state in which the service is provided.

Md. Code Regs. 10.09.95.01

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