Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.06 - Maryland Medical Care Data Base and Data Collection › Section 10.25.06.02 - 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) "Adjudicated" means paid, resolved, or
				  settled.
(2) "Behavioral health
				  care services" means procedures or services rendered by a health care
				  practitioner for the treatment of mental health or substance use disorders.
(3) "Capitated encounter" means a
				  health care visit in which a health care practitioner or office facility
				  provides a service pursuant to an agreement with a reporting entity for
				  reimbursement on an aggregate fixed sum or per capita basis.
(4) "Commission" means the Maryland Health
				  Care Commission.
(5) "Crosswalk"
				  means a list of all codes and their definitions in a separate file that maps to
				  a specific data field.
(6)
				  "Executive Director" means the Executive Director of the Maryland Health Care
				  Commission.
(7) "Fee-for-service
				  encounter" means a health care visit in which a health care practitioner or
				  office facility provided a health care service for which a claim was submitted
				  to a reporting entity for payment, and payment was made on a per service
				  basis.
(8) "General health benefit
				  plan" means:
(a) A hospital or health care
				  policy, contract, or certificate issued by a payor as defined in this
				  section;
(b) A behavioral health
				  services plan;
(c) A pharmacy
				  benefit management services plan;
(d) A vision plan certified by the Maryland
				  Health Benefit Exchange; or
(e) A
				  dental plan certified by the Maryland Health Benefit Exchange.
(9) "Health Benefit Exchange" or
				  "Exchange" means the Maryland Health Benefit Exchange established as a public
				  corporation under Insurance Article, §
											31-102, Annotated Code of
				  Maryland, and includes the Individual Exchange and the Small Business Health
				  Operations Program (SHOP) Exchange.
(10) "Health care service" means a health or
				  medical care procedure or service rendered by a health care practitioner that:
(a) Provides testing, diagnosis, or treatment
				  of human disease or dysfunction; or
(b) Dispenses drugs, medical devices, medical
				  appliances, or medical goods for the treatment of human disease or
				  dysfunction.
(11)
				  "Health information exchange" or "HIE" means an entity that creates or
				  maintains an infrastructure that provides organizational and technical
				  capabilities in an interoperable system for the electronic exchange of
				  protected health information among participating organizations not under common
				  ownership, in a manner that ensures the secure exchange of protected health
				  information to provide care to patients. An HIE does not include an entity that
				  is acting solely as a health care clearinghouse, as defined in
				  45 CFR §
												160.103. A payor may act as, operate, or own
				  an HIE subject to these regulations.
(12) "HIPAA" means the U.S. Health Insurance
				  Portability and Accountability Act of 1996,
				  P.L.
				  104-191, as implemented and amended in federal
				  regulations, including the HIPAA Privacy and Security rules, 45 CFR
				  §§ 160 and 164, as may be amended, modified, or renumbered and
				  including as amended by the Health Information Technology for Economic and
				  Clinical Health (HITECH) Act.
(13)
				  "Managed behavioral health care organization" means a company, organization,
				  private review agent, or subsidiary that:
(a)
				  Contracts with a payor as defined in this section to provide, undertake to
				  arrange, or administer behavioral health care services to members; or
(b) Otherwise makes behavioral health care
				  services available to members through contracts with health care providers.
(14) "Managed care
				  organization" or "MCO" means:
(a) A certified
				  health maintenance organization that is authorized to receive medical
				  assistance prepaid capitation payments; or
(b) A corporation that:
(i) Is a managed care system that is
				  authorized to receive medical assistance prepaid capitation payments;
(ii) Enrolls only program recipients or
				  individuals or families served under the Maryland Children's Health Program;
				  and
(iii) Is subject to the
				  requirements of Health-General Article, §15-102.4, Annotated Code of
				  Maryland.
(15) "Master Patient Index" means a database
				  that maintains a unique index identifier for each patient whose protected
				  health information may be accessible through the HIE and is used to cross
				  reference patient identifiers across multiple participating organizations to
				  allow for patient search, patient matching, and consolidation of duplicate
				  records.
(16) "Medical Care Data
				  Base" or "MCDB" means the data base established and maintained by the
				  Commission pursuant to Health-General Article, § 19-133, Annotated Code of
				  Maryland, that collects eligibility data, professional services claims,
				  institutional services claims, pharmacy claims, and provider data for Maryland
				  residents enrolled in private insurance, Medicaid, or Medicare. The MCDB is
				  Maryland's All Payer Claims Data Base.
(17) "MCDB Submission Manual" or "Manual"
				  means the composition of data reporting requirements with guidelines of
				  technical specifications, layouts, and definitions necessary for filing the
				  reports required by this chapter.
(18) "Non-Fee-for-Service Expenses Report" means a
				  report with information on lump sum payments made by a reporting entity to
				  providers as part of the reporting entity's compensation to the providers for
				  non-claims-based services.
(19)
				  "Office facility" means a freestanding facility providing:
(a) Ambulatory surgery;
(b) Radiologic or diagnostic imagery;
				  or
(c) Laboratory
				  services.
(20) "Payor"
				  means:
(a) An insurer or nonprofit health
				  service plan that holds a certificate of authority and provides health
				  insurance policies or contracts in Maryland;
(b) A health maintenance organization (HMO)
				  that holds a certificate of authority in Maryland; or
(c) For Medical Care Data Base purposes:
(i) A third-party administrator registered
				  under Insurance Article, Title 8, Subtitle 3, Annotated Code of
				  Maryland;
(ii) A managed behavioral
				  health care organization as defined in this section; or
(iii) A pharmacy benefit manager.
(21) "Person" means an
				  individual, receiver, trustee, guardian, personal representative, fiduciary,
				  representative of any kind, partnership, firm, association, corporation, or
				  other entity.
(22) "Pharmacy
				  benefit management services" means:
(a) The
				  procurement of prescription drugs at a negotiated rate for dispensation within
				  the State to beneficiaries;
(b) The
				  administration or management of prescription drug coverage provided by a
				  purchaser for beneficiaries; and
(c) Any of the following services provided
				  with regard to the administration of prescription drug coverage:
(i) Mail service pharmacy;
(ii) Claims processing, retail network
				  management, and payment of claims to pharmacies for prescription drugs
				  dispensed to beneficiaries;
(iii)
				  Clinical formulary development and management services;
(iv) Rebate contracting and
				  administration;
(v) Patient
				  compliance, therapeutic intervention, and generic substitution programs;
				  or
(vi) Disease management
				  programs.
(d) "Pharmacy
				  benefit management services" does not include any service provided by a
				  nonprofit health maintenance organization that operates as a group model,
				  provided that the service is provided solely to a member of the nonprofit
				  health maintenance organization and is furnished through the internal pharmacy
				  operations of the nonprofit health maintenance organization.
(23) "Pharmacy benefit manager"
				  means a person who performs pharmacy benefit management services and is
				  registered as a pharmacy benefit manager under Insurance Article, Title 15,
				  Subtitle 16, Annotated Code of Maryland.
(24) "Practitioner" means a person who is
				  licensed, certified, or otherwise authorized under Health Occupations Article,
				  Annotated Code of Maryland, to provide health care services in the ordinary
				  course of business or practice of a profession or in an approved education or
				  training program.
(25)
				  "Practitioner federal tax ID number" means the federal tax identification
				  number of the practitioner, practice, supplier or office facility receiving
				  reimbursement for the service provided.
(26) "Practitioner/supplier ID number" means
				  the unique identification number used by the reporting entity to identify the
				  particular practitioner or supplier.
(27) "Primary diagnosis" means the principal
				  diagnosis for the health care service visit.
(28) "Provider" means:
(a) A practitioner;
(b) A facility where health care is provided
				  to patients or recipients, including:
(i) A
				  facility, as defined in Health-General Article, §10-101(e), Annotated Code
				  of Maryland;
(ii) A hospital, as
				  defined in Health-General Article, §19-301, Annotated Code of
				  Maryland;
(iii) A related
				  institution, as defined in Health-General Article, §19-301, Annotated Code
				  of Maryland;
(iv) A health
				  maintenance organization, as defined in Health-General Article,
				  §19-701(g), Annotated Code of Maryland;
(v) An outpatient clinic; and
(vi) A medical laboratory; or
(c) The agents and employees of a
				  facility who are licensed or otherwise authorized to provide health care, the
				  officers and directors of a facility, and the agents and employees of a health
				  care provider who are licensed or otherwise authorized to provide health
				  care.
(29) "Qualified
				  dental plan" means a dental plan certified by the Maryland Health Benefit
				  Exchange that provides limited scope dental benefits, as described in §
				  1311(c) of the Affordable Care Act and Insurance Article, § 31-115,
				  Annotated Code of Maryland.
(30)
				  "Qualified health plan" means a general health benefit plan that has been
				  certified by the Maryland Health Benefit Exchange to meet the criteria for
				  certification described in § 1311(c) of the Affordable Care Act and
				  Insurance Article, § 31-115, Annotated Code of Maryland.
(31) "Qualified vision plan" means a vision
				  plan certified by the Maryland Health Benefit Exchange that provides limited
				  scope vision benefits, as described in the Insurance Article, §
											31-108(b)(3),
				  Annotated Code of Maryland.
(32)
				  "Reporting entity" means a payor, third-party administrator, managed behavioral
				  health care organization, or pharmacy benefit manager that is designated by the
				  Commission to provide reports consistent with this chapter to be collected and
				  compiled into the Medical Care Data Base.
(33) "State-designated health information
				  exchange" or "State-designated HIE" means an HIE designated by the Maryland
				  Health Care Commission and the Health Services Cost Review Commission pursuant
				  to the statutory authority set forth in Health General Article, § 19-143,
				  Annotated Code of Maryland.
(34)
				  "Supplier" means a person or entity, including a health care practitioner,
				  which supplies medical goods or services.
(35) "Third-party administrator" means a
				  person that is registered as an administrator under Insurance Article, Title 8,
				  Subtitle 3, Annotated Code of Maryland.