Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.36 - General Medical Assistance Provider Participation Criteria › Section 10.09.36.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  following terms apply to Medical Assistance providers. Additional defined
				  terms, unique to Medical Assistance provided services, are found in Medical
				  Assistance service-specific chapters.
B. Terms Defined.
(1) "Abandoned" means failing to appear for a
				  hearing on the established date without good cause.
(2) "Administrative law judge" means an
				  individual appointed by the Chief Administrative Law Judge under State
				  Government Article, §
											9-1604, Annotated
				  Code of Maryland, or designated by the Chief Administrative Law Judge under
				  State Government Article, §
											9-1607, Annotated
				  Code of Maryland, to:
(a) Adjudicate
				  contested cases at the Maryland Office of Administrative Hearings;
				  and
(b) Render a proposed decision
				  for purposes of COMAR
				  28.02.01.22A.
(3) "Affiliated lines of
				  business " means an individual or entity with an affiliation, as defined in
				  §B(4) of this regulation, to another provider.
(4) "Claim" means:
(a) A bill for services;
(b) A line item of service; or
(c) All services for one participant within a
				  bill.
(5) Clean Claim.
(a) "Clean claim" means a claim that can be
				  processed consistent with applicable regulations without obtaining additional
				  information from the provider of the service or from a third party.
(b) "Clean claim" includes a claim with
				  errors originating in a State's claims system;
(c) "Clean claim" does not include a claim:
(i) From a provider who is under
				  investigation for fraud or abuse; or
(ii) Under review for medical necessity.
(6)
				  "Affiliation " means:
(a) A 5 percent or
				  greater direct or indirect ownership interest that an individual or entity has
				  in another organization;
(b) A
				  general or limited partnership interest that an individual or entity has in
				  another organization;
(c) An
				  interest in which an individual or entity exercises operational or managerial
				  control over or directly or indirectly conducts the day-to -day operations of
				  another organization, either under contract or through some other arrangement,
				  regardless of whether the managing individual or entity is a W - 2 employee of
				  the organization; or
(d) An
				  interest in which an individual is acting as an officer or director of a
				  corporation.
(7) "Care
				  manager" means a:
(a) Primary medical
				  provider under the Diabetes Care Program, in accordance with COMAR 10.09.43, or
				  the Maryland Access to Care Program, in accordance with COMAR
				  10.09.44;
(b) Primary care provider
				  under the corrective managed care program, in accordance with COMAR
				  10.09.24.15BB and
				  10.09.25.14BB; or
(c) Hospice
				  provider under the hospice care program, in accordance with COMAR
				  10.09.35.
(8) "Customary
				  charge" means the uniform amount that the provider charges in the majority of
				  cases for a specific item or service, excluding token charges for charity
				  patients and substandard charges for welfare and other low-income
				  patients.
(9) "Department" means
				  the Department of Health and Mental Hygiene, which is the single state agency
				  designated to administer the Maryland Medical Assistance Program pursuant to
				  Title XIX of the Social Security Act,
				  42 U.S.C. §
												1396 et seq.
(10) "Emergency services" means those
				  services which are provided in hospital emergency facilities after the onset of
				  a medical condition manifesting itself by symptoms of sufficient severity that
				  the absence of immediate medical attention could reasonably be expected by a
				  prudent layperson, possessing an average knowledge of health and medicine, to
				  result in:
(a) Placing health in
				  jeopardy;
(b) Serious impairment to
				  bodily functions;
(c) Serious
				  dysfunction of any bodily organ or part; or
(d) Development or continuance of severe
				  pain.
(11) "Managed care"
				  means the care manager's provision of comprehensive primary care and referral
				  services to an enrollee in a managed care program.
(12) "Managed care program" means:
(a) Maryland Access to Care Program under
				  COMAR 10.09.44;
(b) Diabetes Care
				  Program under COMAR 10.09.43;
(c)
				  Corrective managed care under COMAR
				  10.09.24.15BB or
				  10.09.25.14BB; or
(d) Hospice care
				  under COMAR 10.09.35.
(13) "Medical Assistance Program" means the
				  program of comprehensive medical and other health-related care for indigent and
				  medically indigent persons.
(14)
				  "Medical Care Programs" means the unit of the Department responsible for the
				  administration of the Medical Assistance Program.
(15) Overpayment.
(a) "Overpayment" means any payment made by
				  the Medicaid Program to a provider for medical care provided to a participant
				  which at the time of payment, or at a subsequent date, is determined to be:
(i) A duplicate payment;
(ii) A payment for services for which
				  reimbursement is claimed when all or any part of the claim submitted to the
				  Department is for services that were provided in violation of one or more
				  regulations;
(iii) Excessive in
				  amount; or
(iv) The primary
				  obligation of a health insurance carrier or any other person, including the
				  participant, who is legally or contractually obligated to pay for that medical
				  care.
(b) "Overpayment"
				  does not include an amount recovered as part of a routine cost settlement
				  process.
(16)
				  "Participant" means a person who is certified as eligible for, and is
				  receiving, Medical Assistance benefits.
(17) "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.
(18) Overpayment.
(a) "Overpayment" means any payment made by
				  the Medicaid Program to a provider for medical care provided to a recipient
				  which at the time of payment, or at a subsequent date, is determined to be a
				  duplicate payment, excessive in amount, or the primary obligation of a health
				  insurance carrier or any other person, including the recipient, who is legally
				  or contractually obligated to pay for that medical care.
(b) "Overpayment" does not include an amount
				  recovered as part of a routine cost settlement process.
(19) "Provider" means:
(a) An individual, association, partnership,
				  corporation, unincorporated group, or any other person authorized, licensed, or
				  certified to provide services for Program participants and who, through
				  appropriate agreement with the Department, has been identified as a Program
				  provider by the issuance of an individual account number;
(b) An agent, employee, or related party of a
				  person identified in §B(19)(a) of this regulation; or
(c) An individual or any other person with an
				  ownership interest in a person identified in §B(19)(a) of this
				  regulation.
(20)
				  "Withhold payment" means the Program's decision to not pay or suspend payment
				  to a provider as a sanction for failure to comply with applicable federal or
				  State laws or regulations or because of a credible allegation of
				  fraud.