Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.95 - Special Psychiatric Hospitals › Section 10.09.95.01 - 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) "Administrative day" means a day of
				  medical services delivered to a participant who no longer requires the level of
				  care which the provider is licensed to deliver and is awaiting placement in a
				  nursing home or residential care facility.
(2) "Admission" means the formal acceptance
				  by a specialty psychiatric hospital of a patient who is to be provided with
				  room, board, and medically necessary services in an area of the hospital where
				  patients stay at least overnight.
(3) "Ancillary services" means diagnostic and
				  therapeutic services, provided exclusive of room and board, including but not
				  limited to:
(a) Radiology;
(b) Laboratory tests;
(c) Pharmacy services; and
(d) Physical therapy services.
(4) "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.
(5) "Concurrent review" means a periodic
				  reauthorization of continued eligibility for the level of services provided by
				  a special psychiatric hospital which allows for close monitoring of the
				  participant's progress, treatment goals, and objectives during an inpatient
				  hospitalization.
(6) "Date of
				  service" means:
(a) For inpatient
				  hospitalizations, the date of admission into a special psychiatric 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 special psychiatric
				  hospital; and
(c) For observation
				  services, the date or dates the services are rendered in a special psychiatric
				  hospital, which are ordered by a medical staff practitioner to determine the
				  need for inpatient admission.
(7) "Department" means the State 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.
(8) "Designee" means any entity designated to
				  act on behalf of the Department.
(9) "Electronic signature" means a secure
				  electronic identification of an individual who authorizes an electronic record
				  or transaction.
(10) "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.
(11) "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.
(12) "Level of care" means an assessment that
				  an individual needs the level of services provided in a special psychiatric
				  hospital.
(13) "Maryland Medical
				  Assistance Program" means the program of comprehensive medical and other
				  health-related care for indigent and medically indigent persons.
(14) "Medicaid" means the Maryland Medical
				  Assistance Program.
(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) "Mental health services" means those
				  services described in COMAR
				  10.09.59.06 rendered to treat the
				  diagnoses set forth in COMAR 10.09.70.02.
(18) "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.
(19) "Observation services" means
				  the medically necessary diagnostic services used to assess the participant's
				  outpatient condition to determine the need for possible admission to an
				  inpatient special psychiatric care setting.
(20) "Organ" means a part of an organism that
				  is typically self-contained and has a specific vital function, such as a heart
				  or liver.
(21) "Out-of-State
				  hospital" means any hospital outside of Maryland, except for hospitals located
				  in the District of Columbia.
(22)
				  "Outpatient services" means services provided to the participant on the
				  hospital campus that do not require hospital admission.
(23) "Partial hospitalization" means
				  outpatient, intensive, nonresidential psychiatric treatment, which is an
				  alternative to inpatient acute general hospitalization, for any part of a
				  24-hour day for a minimum of 4 consecutive hours per day.
(24) "Participant" means a person who is
				  certified as eligible for and is receiving Medical Assistance
				  benefits.
(25) "Patient" means an
				  individual awaiting or undergoing health care or treatment.
(26) "Plan of treatment" means a written
				  plan, developed to address the referred problem or problems, which includes:
(a) Diagnosis;
(b) Treatment goals;
(c) Frequency of visits for each type of
				  service ordered;
(d) Duration of
				  treatment of each type of service ordered;
(e) Prognosis; and
(f) Other appropriate items.
(27) "Preauthorization" means the
				  approval required from the Department or its designee before a service can be
				  rendered by the provider and reimbursed.
(28) "Program" means the Maryland Medical
				  Assistance Program.
(29) "Provider"
				  means a special psychiatric hospital which through agreement with the
				  Department has been identified as a Program provider by the issuance of a
				  provider number.
(30)
				  "Retrospective review" means the process of determining medical necessity of an
				  inpatient admission after the participant has been discharged from the
				  hospital.
(31) "Special psychiatric
				  hospital" means an institution that:
(a)
				  Provides short-term services for psychiatric illnesses in a hospital setting
				  with facilities, medical staff, and all necessary personnel to provide
				  diagnosis, care, and treatment;
(b)
				  Falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3,
				  Annotated Code of Maryland; and
(c)
				  Is licensed pursuant to COMAR 10.07.01 or other applicable standards
				  established by the state in which the service is provided.