Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.36 - General Medical Assistance Provider Participation Criteria
Section 10.09.36.01 - Definitions
Universal Citation: MD Code Reg 10.09.36.01
Current through Register Vol. 51, No. 19, September 20, 2024
A. The following terms apply to Medical Assistance providers. Additional defined terms, unique to Medical Assistance provided services, are found in Medical Assistance service-specific chapters.
B. Terms Defined.
(1) "Abandoned" means failing to
appear for a hearing on the established date without good cause.
(2) "Administrative law judge" means an
individual appointed by the Chief Administrative Law Judge under State
Government Article, §9-1604, Annotated
Code of Maryland, or designated by the Chief Administrative Law Judge under
State Government Article, §9-1607, Annotated
Code of Maryland, to:
(a) Adjudicate
contested cases at the Maryland Office of Administrative Hearings;
and
(b) Render a proposed decision
for purposes of COMAR
28.02.01.22A.
(3) "Affiliated lines of
business " means an individual or entity with an affiliation, as defined in
§B(4) of this regulation, to another provider.
(4) "Claim" means:
(a) A bill for services;
(b) A line item of service; or
(c) All services for one participant within a
bill.
(5) Clean Claim.
(a) "Clean claim" means a claim that can be
processed consistent with applicable regulations without obtaining additional
information from the provider of the service or from a third party.
(b) "Clean claim" includes a claim with
errors originating in a State's claims system;
(c) "Clean claim" does not include a claim:
(i) From a provider who is under
investigation for fraud or abuse; or
(ii) Under review for medical necessity.
(6) "Current
Procedural Terminology (CPT)" means the American Medical Association's uniform
nomenclature for coding medical procedures and services.
(7) "Affiliation " means:
(a) A 5 percent or greater direct or indirect
ownership interest that an individual or entity has in another
organization;
(b) A general or
limited partnership interest that an individual or entity has in another
organization;
(c) An interest in
which an individual or entity exercises operational or managerial control over
or directly or indirectly conducts the day-to -day operations of another
organization, either under contract or through some other arrangement,
regardless of whether the managing individual or entity is a W - 2 employee of
the organization; or
(d) An
interest in which an individual is acting as an officer or director of a
corporation.
(8) "Care
manager" means a:
(a) Primary medical
provider under the Diabetes Care Program, in accordance with COMAR 10.09.43, or
the Maryland Access to Care Program, in accordance with COMAR
10.09.44;
(b) Primary care provider
under the corrective managed care program, in accordance with COMAR
10.09.24.15BB and
10.09.25.14BB; or
(c) Hospice
provider under the hospice care program, in accordance with COMAR
10.09.35.
(9) "Customary
charge" means the uniform amount that the provider charges in the majority of
cases for a specific item or service, excluding token charges for charity
patients and substandard charges for welfare and other low-income
patients.
(10) "Healthcare Common
Procedure Coding System (HCPCS)" means the specified code set for procedures
and services, according to the Health Insurance Portability and Accountability
Act (HIPAA).
(10) "Department"
means the Department of Health and Mental Hygiene, which is the single state
agency designated to administer the Maryland Medical Assistance Program
pursuant to Title XIX of the Social Security Act,
42 U.S.C. § 1396 et seq.
(11) "Emergency services" means those
services which are provided in hospital emergency facilities after the onset of
a medical condition manifesting itself by symptoms of sufficient severity that
the absence of immediate medical attention could reasonably be expected by a
prudent layperson, possessing an average knowledge of health and medicine, to
result in:
(a) Placing health in
jeopardy;
(b) Serious impairment to
bodily functions;
(c) Serious
dysfunction of any bodily organ or part; or
(d) Development or continuance of severe
pain.
(12) "Managed care"
means the care manager's provision of comprehensive primary care and referral
services to an enrollee in a managed care program.
(13) "Managed care program" means:
(a) Maryland Access to Care Program under
COMAR 10.09.44;
(b) Diabetes Care
Program under COMAR 10.09.43;
(c)
Corrective managed care under COMAR
10.09.24.15BB or
10.09.25.14BB; or
(d) Hospice care
under COMAR 10.09.35.
(14) "Medical Assistance Program" means the
program of comprehensive medical and other health-related care for indigent and
medically indigent persons.
(15)
"Medical Care Programs" means the unit of the Department responsible for the
administration of the Medical Assistance Program.
(16) Overpayment.
(a) "Overpayment" means any payment made by
the Medicaid Program to a provider for medical care provided to a participant
which at the time of payment, or at a subsequent date, is determined to be:
(i) A duplicate payment;
(ii) A payment for services for which
reimbursement is claimed when all or any part of the claim submitted to the
Department is for services that were provided in violation of one or more
regulations;
(iii) Excessive in
amount; or
(iv) The primary
obligation of a health insurance carrier or any other person, including the
participant, who is legally or contractually obligated to pay for that medical
care.
(b) "Overpayment"
does not include an amount recovered as part of a routine cost settlement
process.
(17)
"Participant" means a person who is certified as eligible for, and is
receiving, Medical Assistance benefits.
(18) "Medicare" means the insurance program
administered by the federal government under Title XVIII of the Social Security
Act, 42 U.S.C. § 1395 et seq.
(19) Overpayment.
(a) "Overpayment" means any payment made by
the Medicaid Program to a provider for medical care provided to a recipient
which at the time of payment, or at a subsequent date, is determined to be a
duplicate payment, excessive in amount, or the primary obligation of a health
insurance carrier or any other person, including the recipient, who is legally
or contractually obligated to pay for that medical care.
(b) "Overpayment" does not include an amount
recovered as part of a routine cost settlement process.
(20) "Provider" means:
(a) An individual, association, partnership,
corporation, unincorporated group, or any other person authorized, licensed, or
certified to provide services for Program participants and who, through
appropriate agreement with the Department, has been identified as a Program
provider by the issuance of an individual account number;
(b) An agent, employee, or related party of a
person identified in §B(19)(a) of this regulation; or
(c) An individual or any other person with an
ownership interest in a person identified in §B(19)(a) of this
regulation.
(21)
"Withhold payment" means the Program's decision to not pay or suspend payment
to a provider as a sanction for failure to comply with applicable federal or
State laws or regulations or because of a credible allegation of
fraud.
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