Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.02 - Physicians' Services › Section 10.09.02.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. The following
				  terms have the meanings indicated.
B. Terms Defined.
(1) "Attending physician" means a physician,
				  other than a house officer, resident, intern, or emergency room physician,
				  directly responsible for the patient's care.
(2) "Board" means the Board of Physician
				  quality Assurance.
(3)
				  "Consultant-specialist" means a licensed physician who meets one of the
				  following criteria:
(a) Has been declared
				  board certified by a member board of the American Board of Medical Specialties
				  and currently retains that status;
(b) Can demonstrate satisfactory completion
				  of a residency program accredited by the Liaison Committee for Graduate Medical
				  Education, or the appropriate Residency Review Committee of the American
				  Medical Association;
(c) Has been
				  declared board certified by a specialty board approved by the Advisory Board of
				  Osteopathic Specialists and the Board of Trustees of the American Osteopathic
				  Association;
(d) Has been declared
				  board eligible by a specialty board approved by the Advisory Board of
				  Osteopathic Specialists;
(e) Can
				  demonstrate, if a residency program was completed in a foreign country, that
				  qualifications and training are acceptable for admission into the examination
				  system of the appropriate American Specialty Board.
(4) "Consultation" means written opinion or
				  advice rendered by a consultant-specialist whose opinion or advice is requested
				  by the patient's attending physician for the further evaluation or management
				  of the patient by the attending physician. If the consultant-specialist assumes
				  responsibility for the continuing care of the patient, a subsequent service
				  rendered by the consultant-specialist is not a consultation. The consultation
				  shall be provided in the specialty in which the consultant-specialist is
				  registered with the Program.
(5)
				  "Cosmetic surgery" means surgery which can be expected to improve a patient's
				  physical appearance, but does not restore or materially improve a body
				  function.
(6) "Department" means
				  the State Department of Health and Mental Hygiene, 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.
(7) "Direct supervision" means that a
				  physician-employer is physically present in the same area of a facility as a
				  nonphysician providing the service or services. A physician may supervise only
				  two nonphysician practitioners at any given time.
(8) "Free-standing clinics" means those
				  clinics not associated with a hospital which are under the direction of a
				  physician or dentist.
(9)
				  "Hospital" means any institution which falls within the jurisdiction of
				  Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, and
				  is licensed pursuant to COMAR 10.07.01.
(10) "Medical Assistance Program" means a
				  program of comprehensive medical and other health-related care for indigent and
				  medically indigent persons.
(11)
				  "Medically necessary" means that the 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 current 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, family, or provider.
(12) "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.
(13) "Medicare-Certified Facility" means one
				  which is certified for Medicare by the regional office of the Health Care
				  Financing Administration to furnish dialysis services directly to chronic
				  kidney disease patients.
(14)
				  "Mental health services" means those services described in COMAR 10.09.70.10CC
				  rendered to treat an individual for a diagnosis set forth in COMAR
				  10.09.70.10A.
(15) "Multispecialty
				  setting" means that type of medical practice which exists in a teaching
				  hospital or in a group practice which is composed of physicians with different
				  specialties.
(16) "Participant"
				  means an individual who is certified as eligible for, and is receiving, Medical
				  Assistance benefits.
(17) "Patient"
				  means a recipient awaiting or undergoing health care or treatment.
(18) "Physician" means an individual legally
				  licensed to practice medicine by the Board or in the state in which the
				  physician's practice is located.
(19) "Preauthorization" means an approval
				  required from the Department or its designee before services can be
				  rendered.
(20) "Preoperative day"
				  means an inpatient day in a general hospital before surgery for a patient
				  admitted for a surgical procedure, or a day before surgery for a patient
				  admitted for a nonsurgical service as an inpatient in a general hospital once
				  the need for surgery has been established and the patient's condition is
				  satisfactory for surgery.
(21)
				  "Prescriber" means a physician, dentist, podiatrist, or other professional
				  authorized to prescribe legend drugs and authorized by the Department to
				  participate in the Program.
(22)
				  "Prescription" means a written order for medication, or medical supplies or
				  equipment, signed by the prescriber.
(23) "Program" means the Maryland Medical
				  Assistance Program.
(24) "Provider"
				  means an individual, association, partnership, or incorporated or
				  unincorporated group of physicians duly licensed or certified to provide
				  services for recipients and who, through appropriate agreement with the
				  Department, has been identified as a Program provider by the issuance of an
				  individual account number.
(25)
				  "Referral" means a transfer of the patient from one physician to another for
				  diagnosis and treatment of the condition for which the referral was made. The
				  physician to whom the referral is made, whether a generalist or specialist,
				  will be considered as the primary care physician and not as a
				  consultant.
(26) "United States"
				  means the 50 states, the District of Columbia, and the U.S.
				  territories.
(27) "Utilization
				  control agent (UCA)" means the organization responsible for reviewing the use
				  of hospital services to determine medical necessity and lengths of stay
				  according to professional standards.