Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.94 - Special Pediatric Hospitals › Section 10.09.94.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
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.