Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.13 - Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) › Section 10.67.13.02 - 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) "Adverse decision" means a review
				  determination by a managed care organization that a health care service for
				  which a provider seeks reimbursement is not medically necessary.
(2) "Affiliate" means a person who, directly
				  or indirectly, through one or more intermediaries, controls, is controlled by,
				  or is under common control with another person.
(3) "Case record" means documentation
				  submitted to an independent review organization consisting of:
(a) A claim and only the supporting
				  documentation, including medical records, originally submitted to a managed
				  care organization by a provider prior to the managed care organization's
				  adverse decision on the claim;
(b)
				  The managed care organization's adverse decision; and
(c) The managed care organization's written
				  rationale for the adverse decision.
(4) "Claim" means a clean claim as defined in
				  COMAR 31.10.11.02.
(5) "Complaint"
				  means an appeal of an adverse decision filed with the independent review
				  organization.
(6) "Department"
				  means the Maryland Department of Health and Mental Hygiene.
(7) "Expert reviewer" means a physician or
				  other appropriate health care provider who contracts with the independent
				  review organization to conduct a review of a managed care organization's
				  adverse decision.
(8) "Health care
				  service" means a health or medical care procedure or service rendered by a
				  provider including:
(a) Testing, diagnosis, or
				  treatment of a human disease or dysfunction;
(b) Dispensing of drugs, medical devices,
				  medical appliances, or medical goods for the treatment of a human disease or
				  dysfunction; or
(c) Any other care,
				  service, or treatment of disease or injury, the correction of defects, or the
				  maintenance of the physical and mental well-being of human beings.
(9) "Independent review
				  organization" means an entity that contracts with the Department to conduct
				  independent review of managed care organizations' adverse decisions.
(10) "Managed care organization (MCO)" has
				  the meaning stated in Health-General Article, §15-101, Annotated Code of
				  Maryland.
(11) "Medicaid" means the
				  program administered by the State under Title XIX of the Social Security Act,
				  which provides comprehensive medical and other health-related care for
				  persons.
(12) "Medical record" has
				  the meaning stated in Health-General Article, §4-301, Annotated Code of
				  Maryland.
(13) "Medically
				  necessary" means a health care service that 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;
(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
				  consumer, the consumer's family, or the provider.
(14) "Provider" means any individual or
				  entity that has a valid provider agreement with a Medicaid managed care
				  organization or is a nonparticipating provider rendering covered Medicaid
				  services to the managed care organization's enrollees.