Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.01 - 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) "Adverse action" means any action taken
				  by the dental benefits administrator (DBA) to deny, reduce, terminate, delay,
				  or suspend a covered service.
(2)
				  "Aftercare" means the period of follow-up care after initial services are
				  rendered, during which any additional related services rendered by the same
				  provider are included in the payment for the original services.
(3) "Ambulatory surgical center (ASC)" means
				  any Medicare-certified entity that operates exclusively for the purpose of
				  providing surgical services to patients not requiring
				  hospitalization.
(4) "Appeal" means
				  the process:
(a) To resolve a participant's
				  dispute with any adverse action taken by the DBA to deny, reduce, terminate,
				  delay, or suspend a covered service; and
(b) Governed by:
(i) COMAR 10.01.04; and
(ii) Any and all applicable court
				  orders.
(5)
				  "Benefits" means a schedule of dental services to be administered by the DBA to
				  Medical Assistance participants pursuant to this chapter.
(6) "Claim" means an itemized statement
				  requesting payment for services rendered by health care providers, such as
				  dentists, billed:
(a)
				  Electronically;
(b) Through a
				  web-based portal; or
(c) Manually
				  on the American Dental Association (ADA) claim form.
(7) "Consultation" means written opinion or
				  advice rendered by a dentist, upon request by the patient's attending physician
				  or dentist, for the further evaluation or management of the patient by the
				  attending physician or dentist. If the consultant dentist assumes
				  responsibility for the continuing care of the patient, a subsequent service
				  rendered by the consultant is not a consultation.
(8) "Dental benefits administrator (DBA)" means an
				  entity with which the Department contracts to administer dental benefits by
				  performing some or all of the following functions:
(a) General administration;
(b) Regulatory compliance;
(c) Network administration;
(d) Member services;
(e) Claims administration;
(f) Data reporting and analysis;
(g) Medical management; or
(h) Quality monitoring.
(9) "Dental services" means emergency,
				  preventive, or therapeutic services for oral diseases which are administered by
				  or under the general supervision of a dentist in the practice of the
				  profession.
(10) "Department" means
				  the State Department of Health and Mental Hygiene, the single State agency
				  designated to administer the Maryland Medical Assistance Program under Title
				  XIX of the Social Security Act,
				  42 U.S.C. §
												1396 et seq., or the Department's
				  designee.
(11) "Early and Periodic
				  Screening, Diagnosis, and Treatment (EPSDT)" means comprehensive and preventive
				  health care pursuant to 42
				  U.S.C. §
												1396d(e) as
				  amended by OBRA 1989.
(12)
				  "Emergency services" means services necessary for the treatment of any
				  condition requiring immediate attention for the relief of pain, hemorrhage,
				  acute infection, or traumatic injury to the teeth, supporting structures (that
				  is, periodontal membranes, gums, and alveolar bone), the jaws, and tissues of
				  the oral cavity.
(13) "EPSDT
				  certified provider" means a physician, physician assistant, or nurse
				  practitioner certified by the Department to provide EPSDT services.
(14) "Free-standing clinic" means a health
				  care facility approved for participation in the Maryland Medical Assistance
				  Program that is not licensed as a hospital or as part of a hospital or nursing
				  home and that is not administratively part of a health maintenance organization
				  or physician's, dentist's, or osteopath's office, but which has a separate
				  staff functioning under the direction of the clinic administrator (as defined
				  in 42 CFR §
												405.1801) or a health officer and which is
				  organized and operated to provide clinic services.
(15) "General supervision" has the meaning
				  stated in COMAR 10.44.21 and 10.44.27.
(16) "Hospital" has the meaning stated in
				  Health-General Article, Title 19, Subtitle 3, Annotated Code of
				  Maryland.
(17) "Maryland Healthy
				  Smiles Dental Program" means the Maryland Medicaid dental program.
(18) "Medical Assistance Program" means the
				  program of comprehensive medical and other health-related care for indigent and
				  medically indigent persons.
(19)
				  "Medically necessary" means that a service or benefit is:
(a) Directly related to diagnostic,
				  preventive, curative, palliative, rehabilitative, or ameliorative treatment of
				  an illness, injury, disability, or health condition;
(b) Consistent with currently accepted
				  standards of good medical practice, dental practice, or both;
(c) The most cost effective service that can
				  be provided without sacrificing effectiveness or access to care; and
(d) Not primarily for the convenience of the
				  consumer, family, or provider.
(20) "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.
(21) "Mobile dental unit" means any
				  self-contained facility in which dentistry will be practiced and which may be
				  moved, towed, or transported from one location to another.
(22) "Network provider" means a health care entity or
				  health care professional that has executed a provider agreement with Maryland
				  Medicaid.
(23) "Participant" means
				  an individual who is certified as eligible for, and is receiving, Medical
				  Assistance benefits.
(24)
				  "Preauthorization" means an approval required from the Department or its
				  designee before the provision of dental or oral health care services.
(25) "Primary dental office" means the fixed
				  and permanent location where the mobile dental unit:
(a) Is linked through either ownership or a
				  legally binding contract; and
(b)
				  Transmits participant records.
(26) "Program" means the Maryland Medical
				  Assistance Program.
(27) "Provider"
				  means:
(a) An individual dentist, duly
				  licensed to provide services for participants, or an association, partnership,
				  or an incorporated or unincorporated group of dentists so licensed, that,
				  through appropriate agreement with the Department, has been identified as a
				  Program provider by the issuance of an individual account number; or
(b) An approved dental school whose students
				  are permitted under Health Occupations Article, §
												4-301(b)(1),
				  Annotated Code of Maryland, to treat dental patients and which, through
				  appropriate agreement with the Department, has been identified as a Program
				  provider by issuance of an individual account number.
(28) "Referral" means a transfer of the
				  patient from a physician or dentist to a dentist for diagnosis and treatment of
				  the condition for which the referral was made. The dentist to whom the referral
				  is made will no longer be considered the consultant.
(29) "REM" means the fee-for-service managed
				  care program for individuals who have certain rare and expensive health care
				  conditions set forth in COMAR 10.09.69.
(30) "Self-ligating braces" means braces
				  which utilize a permanently installed, moveable component to secure the
				  archwire without the use of ligatures.
(31) "Traditional comprehensive orthodontic
				  treatment" means a coordinated diagnosis and treatment to improve craniofacial
				  dysfunction or dentofacial deformity which may utilize fixed and removable
				  orthodontic appliances and focus on specific objectives at various stages of
				  dentofacial development.