Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.92 - Acute Hospitals › Section 10.09.92.01 - 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) ''Acute level of care"
				  means care in which a patient is treated:
(a)
				  For a brief but severe episode of illness, for conditions that are the result
				  of disease or trauma; and
(b)
				  During recovery from surgery.
(3) ''Acute rehabilitation hospital" means an
				  institution devoted to therapy that is designed to facilitate the process of
				  recovery from illness or injury for patients with various neurological,
				  muscular-skeletal, orthopedic, and other medical conditions following
				  stabilization of acute medical issues.
(4) "Administrative day" means a day of
				  medical services delivered to a participant who no longer requires an acute
				  level of care.
(5) "Administrative
				  services organization (ASO)" means an organization with which the Department
				  contracts to assist in the management and operation of the Maryland Public
				  Behavioral Health System.
(6)
				  "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.
(7) "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.
(8) "Concurrent review"
				  means a periodic reauthorization of continued medical eligibility for the level
				  of services provided in an acute hospital which allows for close monitoring of
				  the participant's progress, treatment goals, and objectives during an inpatient
				  hospitalization.
(9) "Date of
				  service" means:
(a) For inpatient
				  hospitalizations, the date of admission into an acute 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 hospital;
(c) For emergency services, the date or dates
				  the services are rendered in the emergency department of an acute hospital;
				  or
(d) For observation services,
				  the date or dates the services are rendered in an acute hospital.
(10) "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.
(11) "Designee" means any
				  entity designated to act on behalf of the Department.
(12) "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, age, sex, and discharge status of the participant.
(13) "Electronic signature" means a secure
				  electronic identification of an individual who authorizes an electronic record
				  or transaction.
(14) "Emergency
				  department" means the area in a hospital that is designed, staffed, and
				  equipped to provide prompt treatment to individuals requiring immediate medical
				  care for acute illness, trauma, and other medical conditions.
(15) "Emergency services" means any health
				  care service provided to evaluate and treat any medical condition where
				  immediate, unscheduled medical care is required.
(16) "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.
(17) "Freestanding medical facility" means a
				  facility:
(a) In which medical and health
				  services are provided;
(b) That is
				  physically separate from a hospital or hospital grounds; and
(c) That is an administrative part of a
				  hospital or related institution.
(18) "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.
(19) "Maryland
				  Medical Assistance Program" means the program of comprehensive medical and
				  other health-related care for indigent and medically indigent
				  individuals.
(20) "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.
(21)
				  "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.
(22) "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.
(23) "Observation services" means
				  the medically necessary services used to assess the participant's outpatient
				  condition to determine the need for possible admission to an inpatient acute
				  care setting.
(24) "Organ" means a
				  part of an organism that is typically self-contained and has a specific vital
				  function, such as a heart or liver.
(25) "Out-of-State hospital" means any
				  hospital outside of Maryland, except for hospitals located in the District of
				  Columbia.
(26) "Outpatient
				  services" means nonemergency services provided to the participant on the
				  hospital campus that do not require hospital admission.
(27) "Participant" means an individual who is
				  enrolled with the Department to receive Medical Assistance services.
(28) "Patient" means an individual awaiting
				  or undergoing health care or treatment.
(29) "Preauthorization" means the approval
				  required from the Department or its designee before a service can be rendered
				  by the provider and reimbursed.
(30) "Preoperative day" means an inpatient
				  day in an acute hospital before:
(a) Surgery
				  for a participant who is being admitted for surgery; or
(b) A surgical procedure when the participant
				  was admitted for a nonsurgical procedure but the need for surgery arose during
				  that stay.
(31)
				  "Program" means the Maryland Medical Assistance Program.
(32) "Prospective payment system" means a
				  predetermined amount of reimbursement per day for inpatient hospital
				  services.
(33) "Provider" means an
				  acute hospital which, through agreement with the Department, has been
				  identified as a Program provider by the issuance of a provider
				  number.
(34) "Retrospective review"
				  means the process of determining medical necessity of an inpatient admission
				  after the participant has been discharged from the hospital.
(35) "Specialty behavioral health" means
				  services as defined in COMAR
				  10.09.70.02D and
				  F.