reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.06 - Maryland Medical Care Data Base and Data Collection › Section 10.25.06.14 - Non-Fee-for-Service Expenses Report

Current through Register Vol. 51, No. 14, July 12, 2024
Each non-fee-for-service expenses report shall contain the
					 information specified by the Commission in its annual update to the MCDB
					 Submission Manual and be filed in a form and manner specified in the
					 Manual.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.06 - Maryland Medical Care Data Base and Data Collection › Section 10.25.06.15 - Report Submission Methods

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  When a reporting entity collects more granular information than required under
				  this chapter, the reporting entity shall provide a conversion table that
				  describes how internal values are mapped to each required category.
B. The MCDB Submission Manual shall contain
				  technical specifications, layouts, required reports, and definitions for each
				  reporting entity.
(1) The Commission shall
				  provide an annual MCDB Submission Manual by November 21 of each year to be used
				  for the reporting periods in the subsequent year.
(2) The Commission may correct incomplete or
				  erroneous information in the MCDB Submission Manual as necessary, and provide
				  notice of each correction on the Commission website and by email to the contact
				  persons designated by the reporting entities.
(3) The Commission shall timely post the
				  annual MCDB Submission Manual on the Commission website and provide notice in
				  the Maryland Register.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.06 - Maryland Medical Care Data Base and Data Collection › Section 10.25.06.16 - Request for an Extension of Time

Current through Register Vol. 51, No. 14, July 12, 2024
A. A reporting entity may request an
				  extension of an additional 30 days time to provide the required data
				  report.
B. For a 30-day extension
				  request to be considered by Commission staff, the reporting entity shall submit
				  a written request to the Executive Director at least 30 days before the
				  required submission date that includes:
(1)
				  The extraordinary cause necessitating the extension request; and
(2) A proposed date, which is no more than 30
				  days after the initial required submission date, when the reporting entity will
				  provide the required data to the Commission.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.06 - Maryland Medical Care Data Base and Data Collection › Section 10.25.06.17 - Request for an Annual Waiver or Format Modification

Current through Register Vol. 51, No. 14, July 12, 2024
A. Annual Waiver Request.
(1) When a reporting entity is not able to
				  submit a data report as set forth in this chapter, the reporting entity shall
				  file with the Commission by March 15 of the year for which a waiver is sought a
				  written request for an annual waiver that shall include an explanation of why
				  the reporting entity is not able to provide the data report, including any
				  extraordinary circumstances.
(2)
				  Supporting Documentation Required for an Annual Waiver Request.
(a) A general health benefit plan shall
				  include an affidavit from an officer of the organization stating that its total
				  lives covered does not exceed 1,000, as reported to the Maryland Insurance
				  Administration.
(b) A qualified
				  health benefit plan, a qualified vision plan or a qualified dental plan shall
				  include a relevant document from the Health Benefit Exchange indicating that
				  the entity's filing of the data is not required.
(c) A third party administrator shall include
				  an affidavit from an officer of the organization stating that its total lives
				  covered does not exceed 1,000, as reported to the Maryland Insurance
				  Administration.
(d) A behavioral
				  health care services organization shall include an affidavit from an officer of
				  the organization stating that its total lives covered does not exceed 1,000, as
				  reported to the Maryland Insurance Administration.
(e) A pharmacy benefit manager shall include
				  an affidavit from an officer of the organization stating that its total lives
				  covered does not exceed 1,000.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.06 - Maryland Medical Care Data Base and Data Collection › Section 10.25.06.18 - Failure to File Data Reports

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  A reporting entity that does not timely file a data report in compliance with
				  the MCDB Submission Manual may be subject to monetary penalties as provided in
				  COMAR 10.25.12.
B. In accordance
				  with COMAR
				  10.25.12.01C, a
				  data report that is substantially incomplete or inaccurate is not timely filed
				  within the meaning of §A of this regulation and may be subject to monetary
				  penalties as provided in COMAR 10.25.12.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.06 - Maryland Medical Care Data Base and Data Collection › Section 10.25.06.19 - Summaries and Compilations

Current through Register Vol. 51, No. 14, July 12, 2024
The Commission shall develop public-use data, summaries,
					 and compilations for public disclosure, pursuant to Health-General Article,
					 §§19-103(c)(3), 19-109(a)(6), and 19-134, Annotated Code of Maryland,
					 in compliance with all applicable federal and State laws and
					 regulations.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter provides for the certification of electronic
					 health networks and medical care electronic claims clearinghouses that operate
					 in Maryland. Payors that accept electronic health care transactions originating
					 in Maryland may only accept electronic health care transactions from electronic
					 health networks or medical care electronic claims clearinghouses that obtain
					 certification pursuant to this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.02 - 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) "Adjudication of claims" means the
				  activities necessary for the adjudication or subrogation of a health benefit
				  claim that has been filed or may be filed by a patient, or with the
				  authorization of a patient on the patient's behalf, including:
(a) Determinations of eligibility or
				  coverage, including coordination of benefits or the determination of
				  cost-sharing amounts;
(b)
				  Reasonable prospective, concurrent, or retrospective utilization review or
				  predetermination of benefit coverage;
(c) Review, audit, and investigation of a
				  specific claim for payment of benefits with respect to medical necessity,
				  coverage under a health plan, appropriateness of care, or justification of
				  charges;
(d) Billing, claims
				  management, collection activities, obtaining payment under a contract for
				  reinsurance, and related health care data processing; and
(e) Risk adjustments based on enrollee health
				  status and demographic characteristics.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.03 - Duration of Certification

Current through Register Vol. 51, No. 14, July 12, 2024
A certification is valid for a 2-year period from the date
					 of certification unless withdrawn by the Commission prior to the end of the
					 2-year period.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.04 - Procedure to Obtain Certification

Current through Register Vol. 51, No. 14, July 12, 2024
A. Application
				  for Certification. An EHN seeking Commission certification shall:
(1) Complete and submit an application for
				  MHCC Electronic Health Network Certification in the form and manner specified
				  by the Commission;
(2) Provide
				  evidence that it has been granted either candidacy status or full accreditation
				  or certification status by a qualified accreditation or certification
				  organization; and
(3) Meet all
				  Commission certification requirements set forth in Regulation .05 of this
				  chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.05 - Standards for Certification

Current through Register Vol. 51, No. 14, July 12, 2024
A. In order to
				  obtain certification, an applicant shall:
(1)
				  Provide evidence that the applicant is accredited or certified by a qualified
				  accreditation or certification organization; and
(2) Meet the following standards for
				  certification:
(a) Demonstrate compliance with
				  the HIPAA privacy standards set forth in 45 CFR Parts 160 and 164;
(b) Demonstrate compliance with HIPAA
				  security standards set forth in 45 CFR Parts 160, 162, and 164;
(c) Provide an attestation signed by an
				  officer of the applicant that the applicant restricts disclosure of legally
				  protected health information as required by Health-General Article,
				  §4-302.5, Annotated Code of Maryland;
(d) Provide evidence of ability to measure
				  technical performance and manage future capacity demands;
(e) Provide evidence of initial and ongoing
				  employee training in HIPAA privacy and security requirements and customer
				  communication procedures; and
(f)
				  Provide additional information requested by the Commission as necessary to
				  determine the applicant's compliance with the standards for
				  certification.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.06 - Candidacy Status

Current through Register Vol. 51, No. 14, July 12, 2024
A. Subject to
				  the provisions of this section, the Commission shall issue candidacy status to
				  an applicant that:
(1) Has been granted
				  candidacy status by a qualified accreditation or certification
				  organization;
(2) Has submitted an
				  application for certification to the Commission;
(3) Has paid the application fee;
				  and
(4) Has submitted documentation
				  satisfactory to the Commission demonstrating compliance with the requirements
				  set forth in Regulation .05B of this chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.07 - Notice Required

Current through Register Vol. 51, No. 14, July 12, 2024
A. Within
				  30 days after the closure, sale, lease, assignment, or transfer of an
				  MHCC-certified EHN to any person or entity, the MHCC-certified EHN and the
				  other party to the transaction shall notify the Commission of that event. Upon
				  such notice, the Commission may seek further information to determine whether
				  the certification should remain in effect notwithstanding the sale or other
				  event.
B. At least 60 days before
				  changing its address, an MHCC-certified EHN shall notify the Commission of its
				  intent and provide the Commission with the new address.
C. At least 60 days before changing its name,
				  an MHCC-certified EHN shall notify the Commission of its intent to change its
				  name and provide the Commission with the new name.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.08 - Renewal of Certification

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Application for renewal of certification shall be made at least 60 days before
				  the expiration of the certification in a form and manner specified by the
				  Commission.
B. A recertification
				  fee shall be paid to the Commission at the time the MHCC Electronic Health
				  Network recertification application is filed.
C. For an electronic health network with one
				  operational site, a recertification fee of $250 shall be paid at the time the
				  application is filed.
D. For an
				  electronic health network with more than one operational site, a
				  recertification fee of $250, plus a $125 fee for each additional operational
				  site, shall be paid at the time the application is filed.
E. The Commission shall renew the
				  certification of each renewal applicant that continues to meet the standards
				  set forth in Regulation .05 of this chapter.
F. The Commission shall issue a renewal of
				  certification to an applicant that has met all the requirements of this
				  regulation.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.09 - Withdrawal of Certification and Other Penalties

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Commission may withdraw certification from an MHCC-certified EHN if the
				  Commission finds that:
(1) The MHCC-certified
				  EHN fails to meet the certification standards set forth in Regulation .05 of
				  this chapter;
(2) A principal or
				  owner of the MHCC-certified EHN, or the entity itself, is convicted of, or
				  pleads guilty or nolo contendere to, a crime related to the operation of the
				  EHN or to a crime involving financial improprieties;
(3) A principal or owner of the MHCC-certified EHN, or
				  the entity itself, is notified by a qualified accreditation or certification
				  organization or the Commission of a violation of HIPAA privacy or security
				  standards and fails to take action to remedy the violation within the period of
				  time specified by a qualified accreditation or certification organization or by
				  the Commission;
(4) The
				  MHCC-certified EHN disclosed legally protected health information in violation
				  of Health-General Article, §4-302.5, Annotated Code of Maryland;
				  or
(5) The MHCC-certified EHN
				  violated a provision of COMAR 10.25.18.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.10 - Notice Prior to Withdrawal

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Before withdrawal of certification on one of the bases provided in Regulation
				  .09 of this chapter, the Executive Director shall inform the MHCC-certified
				  EHN, setting forth in writing the reasons for withdrawal.
B. The notice of withdrawal shall set forth
				  the right of the MHCC-certified EHN to an evidentiary hearing, conducted in
				  accordance with Regulation .11 of this chapter, to show cause why the
				  certification should not be withdrawn.
C. Within 15 days of receipt of the notice of
				  withdrawal, the MHCC-certified EHN may make a written filing that details the
				  EHN's position and provides supporting documentation, before the Commission
				  takes final action to withdraw the EHN's certification.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.07 - Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses › Section 10.25.07.11 - Hearing Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Reviewer as Presiding Officer.
(1) If an
				  evidentiary hearing is requested, the Executive Director shall appoint a single
				  commissioner to act as reviewer and preside at the hearing.
(2) The reviewer shall hold a prehearing
				  conference, at which the reviewer shall:
(a)
				  Summarize the rules of procedure governing the evidentiary hearing;
(b) Determine the date, time, and place of
				  the evidentiary hearing;
(c)
				  Determine the form and manner of the presentation of evidence;
(d) Rule on any pending motions;
				  and
(e) Make other decisions as
				  appropriate.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.08 - Evaluation of Quality and Performance of Health Benefit Plans › Section 10.25.08.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to each carrier that participates in
					 the health benefit plan quality and performance evaluation system.
This chapter requires participation in the health benefit
					 plan quality and performance evaluation system by each carrier that:
(1) Holds a certificate of authority in the
				  State;
(2) Has a premium volume in
				  Maryland for each category of health benefit plan that exceeds $1,000,000;
				  and
(3) Has no more than 65 percent
				  of its Maryland enrollees covered through the Medicaid and Medicare Programs
				  (for each category of health benefit plan), as reported in an annual statement
				  submitted by a carrier to the Commission that includes premium volume and
				  enrollment percentages for the calendar year preceding the reporting period.
The evaluation system described in this chapter is designed
					 to address the information needs of consumers and purchasers by providing an
					 assessment of the quality and performance of health benefit plans based on
					 measures endorsed or implemented by nationally recognized organizations
					 involved in quality of care and performance measurement.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.08 - Evaluation of Quality and Performance of Health Benefit Plans › Section 10.25.08.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
In this chapter, the following terms have the meanings
					 indicated.
Terms Defined.
(1)
				  "Carrier" means an insurer or nonprofit health service plan that holds a
				  certificate of authority and provides health insurance policies or contracts in
				  the State in accordance with Insurance Article, Annotated Code of Maryland, or
				  a health maintenance organization that holds a certificate of authority in the
				  State.
(2) "Commission" means the
				  Maryland Health Care Commission.
(3) Health Benefit Plan.
(a) "Health benefit plan" means a hospital or
				  medical policy, contract, or certificate issued by a carrier.
(b) "Health benefit plan" does not include:
(i) Coverage for accident or disability
				  income insurance;
(ii) Coverage
				  issued as a supplement to liability insurance;
(iii) Liability insurance, including general
				  liability insurance and automobile liability insurance;
(iv) Workers' compensation or similar
				  insurance;
(v) Automobile or
				  property medical payment insurance;
(vi) Credit-only insurance;
(vii) Coverage for on"site medical
				  clinics;
(viii) Dental or vision
				  insurance;
(ix) Long-term care
				  insurance or benefits for nursing home care, home health care, community-based
				  care, or any combination of these;
(x) Coverage only for a specified disease or
				  illness;
(xi) Hospital indemnity or
				  other fixed indemnity insurance or a hospital or medical policy, contract, or
				  certificate issued by a carrier; or
(xii) If offered as a separate insurance
				  policy, Medicare supplemental health insurance, as defined in § 1882(g)(1)
				  of the Social Security Act, coverage supplemental to the coverage provided
				  under Chapter 55 of Title 10 of the United States Code, or similar supplemental
				  coverage provided under an employer sponsored plan.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.08 - Evaluation of Quality and Performance of Health Benefit Plans › Section 10.25.08.04 - Audits

Current through Register Vol. 51, No. 14, July 12, 2024
In order to verify the validity, reliability, and
					 comparability of HEDIS and other performance measures required by the
					 Commission, a carrier shall participate in certified audits as specified by the
					 Commission, which may include:
(1) A
				  process audit;
(2) One or more site
				  visits;
(3) Specification and
				  source code review and verification; and
(4) Medical records review.
Each carrier that is required to participate or elects to
					 participate in the health benefit plan quality and performance evaluation
					 system shall submit audited HEDIS and other performance measures for each
					 designated health benefit plan for the reporting period to the Commission or
					 its contractor by June 1 of the reporting period.
Within the time period specified by the Commission, a
					 carrier shall correct inaccurate or incomplete data contained in its
					 performance measures report that become apparent during the audit or other
					 process.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.08 - Evaluation of Quality and Performance of Health Benefit Plans › Section 10.25.08.05 - Extension of Time

Current through Register Vol. 51, No. 14, July 12, 2024
A carrier may request an extension of not more than 30 days
					 for submission of the performance measures report.
A request for an extension of time shall:
(1) Be submitted to the Executive Director of
				  the Commission not later than 30 days before the carrier's performance measures
				  report is due;
(2) Explain the good
				  cause for the requested extension; and
(3) Propose a reasonable date certain, not to
				  exceed 30 days after the original due date, for submission of the performance
				  measures report.
A carrier may seek Commission review of the Executive
					 Director's denial of a requested extension of time by filing a written petition
					 for review within 7 days of receipt of the denial.
The Commission shall provide the carrier with an
					 opportunity to present its position to the Commission, and may affirm, reverse,
					 or modify the decision of the Executive Director.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.08 - Evaluation of Quality and Performance of Health Benefit Plans › Section 10.25.08.06 - Penalty for Failure to File Reports

Current through Register Vol. 51, No. 14, July 12, 2024
A carrier that is required to participate under Regulation
					 .01B of this chapter and that does not timely file a performance measures
					 report may be subject to the penalties provided in COMAR
					 10.25.12.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter
				  applies to a third-party payer operating in the State of Maryland, as of July
				  1, 1997, whose premium volume exceeds $1,000,000 as reported in the most recent
				  annual statement in the hands of the Maryland Insurance Administration as of
				  December 1 of each calendar year.
B. At the discretion of the Maryland Health
				  Care Commission, this chapter may also apply to third party payers operating in
				  the State of Maryland whose premium volume is $1,000,000 or less.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.02 - 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) "Adjudication" means paid, resolved, or
				  settled.
(2) "Commission" or "MHCC"
				  means the Maryland Health Care Commission.
(3) "HIPAA" means the Health Insurance
				  Portability and Accountability Act of 1996, P.L. No. 104-191, 42 U.S.C. Title
				  XI, Part C.
(4) "Deputy Director"
				  means the Deputy Director for Data Systems and Analysis at the Maryland Health
				  Care Commission, or the Deputy Director's designee.
(5) "Designate" means to select and to enter
				  into a written agreement with.
(6)
				  "Designated EHNs" means MHCC-certified EHNs that have been selected by a payer
				  to submit electronic health care transactions under a written service agreement
				  with the payer on behalf of health care practitioners.
(7) Electronic health care transactions"
				  means health care transactions that are defined under HIPAA Transaction and
				  Code Set Standards.
(8) "Electronic
				  health network (EHN)" means an entity that processes or facilitates processing
				  of electronic transactions in standard or nonstandard formats, between two or
				  more trading partners in the health care community.
(9) "MHCC-certified electronic health
				  network" means an entity that has received certifications from the Maryland
				  Health Care Commission.
(10)
				  "Health insurance claim" means a submission of a claim to a third-party payer
				  for payment for services rendered by a health care practitioner in
				  Maryland.
(11) "Third-party payer"
				  or "payer" means a person that administers or provides reimbursement for health
				  care benefits on an expense-incurred basis, including a:
(a) Health maintenance organization issued a
				  certificate of authority in accordance with Health-General Article, Title 19,
				  Subtitle 7, Annotated Code of Maryland;
(b) Health insurer or nonprofit health
				  service plan authorized to offer health insurance policies or contracts in this
				  State in accordance with Insurance Article, Title 14, Annotated Code of
				  Maryland;
(c) Third-party
				  administrator registered under Insurance Article, Title 14, Annotated Code of
				  Maryland;
(d) Specialty payers,
				  such as Pharmacy Benefit Managers (PBMs); or
(e) Managed Care Organizations (MCOs) which
				  contract with Maryland Medicaid to provide health services to Medicaid
				  enrollees.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.03 - EHN Designation

Current through Register Vol. 51, No. 14, July 12, 2024
A. Payers
				  shall only contract with MHCC-certified EHNs for the exchange of electronic
				  health care transactions that originate in Maryland.
B. In the event that a designated EHN loses
				  its MHCC-certified status, the Commission shall provide written notice to the
				  payer of the event.
C. Within 60
				  days from the date of the notice, the payer shall notify the Commission that it
				  is no longer using that EHN for the exchange of electronic health care
				  transactions.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.04 - Designation Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
The payer and its designated EHNs shall enter into a
					 written agreement that shall address at minimum each of the following:
A. Transaction format
				  specifications;
B. Transmission
				  methods to be used;
C. Schedules of
				  events, such as transmission cutoffs, acknowledgment requirements, reporting
				  requirements, and scheduled outages, etc;
D. Editing requirements and schedules for
				  changes or enhancements;
E. Charges
				  and terms of payment; and
F. System
				  access security requirements.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.05 - EDI Progress Report

Current through Register Vol. 51, No. 14, July 12, 2024
A. On
				  or before June 30 of each year, each payer shall submit to the Commission an
				  EDI Progress Report Form, describing certain electronic health care transaction
				  activity for the payer's previous calendar year as described in this
				  regulation.
B. This report shall
				  include:
(1) A certification of compliance
				  with Health-General Article, §4-302.1, Annotated Code of
				  Maryland;
(2) Health care
				  transactions as defined by HIPAA Transaction and Code Set Standards that are
				  submitted or received by Maryland health care providers;
(3) Electronic transaction activity between
				  January 1 and December 31 of the previous year; and
(4) The total number of HIPAA electronic
				  transactions submitted or received by Maryland health care providers, as
				  defined in the EDI Progress Report Form.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.06 - Waiver or Exception Request

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  A payer may submit a written request for waiver or exception of the reporting
				  requirements.
B. The payer shall:
(1) Submit a written request for a waiver or
				  exception to the Deputy Director not later than 30 days before the due date of
				  meeting the reporting/designation requirements; and
(2) Explain the reason for the waiver
				  request.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.07 - Extension of Time

Current through Register Vol. 51, No. 14, July 12, 2024
A. A payer may
				  request an extension of time of up to 60 days for submission of the EDI
				  information.
B. The payer shall:
(1) Submit the request in writing to the
				  Deputy Director for Data Systems and Analysis not later than 30 days before the
				  reporting deadline;
(2) Explain the
				  reason for the extension request; and
(3) Propose a reasonable date for
				  submission.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.08 - Penalties for Failure to File a Report

Current through Register Vol. 51, No. 14, July 12, 2024
A. Unless the Deputy Director has granted an
				  extension of time, a payer that does not timely file a report is liable for a
				  monetary penalty of $1,000 per day for each day the filing of the report is
				  delayed.
B. A report that is
				  substantially incomplete or inaccurate is not timely filed.
C. The filing of a written petition for
				  review of a denial of an extension of time stays the accrual of the monetary
				  penalty under §A of these regulations.
D. If the Commission affirms the action of
				  the Deputy Director to deny a payer's request for an extension of time, the
				  Commission may impose all penalties in full or in part which, absent the stay,
				  would have accrued during the pendency of the review.
E. For substantial reasons shown, the
				  Commission may suspend, reduce, or waive any penalty imposed under this
				  chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.09 - Requirements for Payers to Designate Electronic Health Networks › Section 10.25.09.09 - Penalties for Failure to Contract with a MHCC-Certified EHN

Current through Register Vol. 51, No. 14, July 12, 2024
A. Unless the
				  Deputy Director has granted an extension of time, a payer that does not
				  contract with an MHCC-Certified EHN within 60 days of notification by MHCC that
				  the EHN is not certified, is liable for a monetary penalty of $1,000 per
				  day.
B. The filing of a written
				  petition for an extension of time stays the accrual of the monetary penalty
				  under §A of this regulation.
C. If the Commission affirms the action of
				  the Deputy Director to deny a payer's request for an extension of time, the
				  Commission may impose all penalties in full or in part which, absent the stay,
				  would have accrued during the pendency of the review.
D. For substantial reasons shown, the
				  Commission may suspend, reduce, or waive any penalty imposed under this
				  chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter
				  applies to trauma physicians and Maryland Institute for Emergency Medical
				  Services Systems designated trauma centers, Maryland Trauma Specialty Referral
				  Centers, and rehabilitation hospitals that are affiliated with Maryland
				  Institute for Emergency Medical Services Systems designated trauma centers by
				  common ownership, as defined in Health-General Article, §19-130(a)(3) and
				  (4), Annotated Code of Maryland, that provide trauma care.
B. Reimbursement.
(1) Trauma physicians seeking reimbursement
				  for uncompensated care provided to trauma patients shall file a claim pursuant
				  to this chapter to receive reimbursement from the Maryland Trauma Physician
				  Services Fund.
(2) Trauma
				  physicians seeking reimbursement for trauma care provided to trauma patients
				  enrolled in the Maryland Medical Assistance Program at the elevated rate shall
				  comply with special billing requirements pursuant to this chapter.
(3) Trauma centers seeking reimbursement for
				  costs of maintaining trauma physicians on-call shall file a claim to receive
				  reimbursement from this Fund.
(4)
				  Trauma centers seeking reimbursement for standby costs shall file a claim to
				  receive reimbursement from this Fund.
(5) Trauma centers seeking trauma grants
				  shall file an application to receive a grant from this Fund.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.03 - Fund Administration

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Fund is a special, nonlapsing interest bearing fund that is not subject to
				  State Finance and Procurement Article, §
										7-302,
				  Annotated Code of Maryland.
B. The
				  purpose of the Fund is to subsidize the documented costs:
(1) Of uncompensated care incurred by a
				  trauma physician in providing trauma services to a trauma patient on the
				  Maryland Trauma Registry;
(2) Of
				  undercompensated care incurred by a trauma physician in providing trauma
				  services to an enrollee of the Medicaid Program who is a trauma patient on the
				  Maryland Trauma Registry;
(3)
				  Incurred by a trauma center to maintain trauma physicians on-call as required
				  by MIEMSS;
(4) Incurred by a trauma
				  center to maintain trauma equipment or systems as required by MIEMSS;
				  and
(5) Incurred by the Commission
				  to administer the Fund and audit reimbursement requests and trauma grants to
				  assure appropriate payments are made from the Fund.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.04 - Source of Fund Revenue

Current through Register Vol. 51, No. 14, July 12, 2024
A. The
				  Fund consists of motor vehicle registration surcharges paid into the Fund in
				  accordance with Transportation Article, §
										13-954(b),
				  Annotated Code of Maryland, and regulations promulgated under that
				  authority.
B. The Commission shall
				  make reimbursement from the Fund for:
(1)
				  On-call costs;
(2) Uncompensated
				  care costs;
(3) Medicaid
				  differential payments;
(4) Standby
				  expenses to an out-of-State pediatric trauma center that has entered into an
				  agreement with the Maryland Institute for Emergency Medical Services
				  Systems;
(5) Trauma equipment;
				  and
(6) The Commission's
				  administrative expenses.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.05 - Who May Request Payment

Current through Register Vol. 51, No. 14, July 12, 2024
A. A
				  trauma physician as defined in Regulation .02 of this chapter may request
				  payment under this chapter.
B.
				  Medicaid and Uncompensated Care Reimbursement.
(1) Trauma Physician Services. A faculty
				  practice plan, a physician practice, a trauma center on behalf of the trauma
				  physician, or an individual trauma physician may submit requests for payment
				  for trauma services provided to a Medicaid trauma patient or for uncompensated
				  care trauma services if:
(a) Those services
				  are provided to a trauma patient during the service period as defined in this
				  chapter; and
(b) The physician
				  meets the definition of a trauma physician under Regulation .02 of this
				  chapter.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.06 - Payments for Medicaid Trauma Patients

Current through Register Vol. 51, No. 14, July 12, 2024
A. A trauma physician:
(1) Is eligible for payment from the Fund for
				  trauma services provided to a Medicaid trauma patient on the Maryland Trauma
				  Registry on or after July 1, 2006; and
(2) May seek reimbursement in accordance with
				  this regulation.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.07 - Payments for Uncompensated Care Patients

Current through Register Vol. 51, No. 14, July 12, 2024
A. A trauma physician:
(1) Is eligible for payment from the Fund for
				  trauma services provided to uncompensated trauma care patients with an
				  admission date on the Maryland Trauma Registry beginning on or after July 1,
				  2006; and
(2) May seek
				  reimbursement in accordance with this regulation.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.08 - On-Call Payment

Current through Register Vol. 51, No. 14, July 12, 2024
A. Eligibility.
				  The Fund will reimburse trauma centers' on-call costs to maintain surgeons
				  on-call in conformance with MIEMSS' regulations at COMAR 30.08.05-30.08.14 for
				  the minimum number of trauma physicians required to be on-call. Trauma centers
				  are eligible for on-call payments as follows:
(1) The Level I trauma center and pediatric
				  trauma center are eligible for on-call payments for on-call hours provided by
				  trauma specialties designated in §B of this regulation on or after July 1,
				  2008;
(2) Level II trauma centers
				  are eligible for on-call payments for on-call hours provided by trauma
				  specialties designated in §C of this regulation;
(3) Level III trauma centers are eligible for
				  on-call payments for on-call hours provided by trauma specialties designated in
				  §D of this regulation; and
(4)
				  Maryland Trauma Specialty Referral Centers are eligible for on-call payments
				  for on-call hours provided by trauma specialties designated in §E of this
				  regulation on or after July 1, 2008.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.09 - Payment for Standby Costs at an Out-of-State Pediatric Center

Current through Register Vol. 51, No. 14, July 12, 2024
A. An out-of-State
				  pediatric trauma center that has entered into an agreement with the Maryland
				  Institute for Emergency Medical Services Systems shall be eligible for an
				  annual grant of up to $590,000 for standby expenses related to the provision of
				  trauma care to Maryland residents.
B. An out-of-State pediatric trauma center
				  shall submit an application for standby expenses incurred in the previous
				  fiscal year using guidelines developed by the Health Services Cost Review
				  Commission.
C. The out-of-State
				  pediatric trauma center shall submit the standby application for the previous
				  fiscal year to the Commission by August 15 of each year.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.10 - Trauma Equipment Grants

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Eligibility.
(1) The Commission, in
				  consultation with the Health Services Cost Review Commission and the Maryland
				  Institute for Emergency Medical Services Systems, shall develop a process for
				  the award of grants to Level II and Level III trauma centers in the State to be
				  used for equipment primarily used in the delivery of trauma care.
(2) The process developed by the Commission
				  for the award of grants shall include:
(a)
				  Grant applications and review and selection criteria for the award of
				  grants;
(b) Review by the
				  Commission, if necessary, for any project that exceeds Certificate of Need
				  thresholds; and
(c) Any other
				  procedure determined necessary by the Commission.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.11 - Equitable Payment Under the Fund

Current through Register Vol. 51, No. 14, July 12, 2024
A. Disbursement from the Fund is subject to
				  the availability of funds.
B. The
				  Commission shall adjust reimbursement formulas used for Medicaid trauma
				  services, uncompensated care trauma services, on-call payments, and standby
				  payments to an out-of-State pediatric trauma center to preserve the
				  distribution of monies in the Fund.
C. Revenue; Payments.
(1) On or before May 1 of each year, the
				  Commission shall determine appropriate levels of payment that can be sustained
				  for the upcoming fiscal year beginning July 1, given the expected revenue in
				  the Fund.
(2) If expected revenue
				  in the Fund is insufficient to meet expected payments, the Medicaid
				  differential payments, uncompensated care shortfall payments, trauma center
				  on-call payments, and standby payments to an out-of-State pediatric trauma
				  center shall be adjusted by the same rate to maintain solvency in the
				  Fund.
(3) The Commission shall
				  maintain a sufficient balance in the Fund to assure equitable payments across a
				  fiscal year.
(4) If Fund payments
				  require adjustment, the Commission shall report to the trauma centers and the
				  trauma physicians listed on trauma center rosters the expected payment levels
				  for the upcoming State fiscal year by June 30.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.12 - Filing of On-call Applications and Uncompensated Care Claims

Current through Register Vol. 51, No. 14, July 12, 2024
A. In order to
				  receive a payment from the Fund, a faculty practice plan, a physician practice
				  plan, a trauma physician, or a trauma center on behalf of a trauma physician
				  shall submit a timely and complete on-call services application or an
				  uncompensated services claim that includes the information required in this
				  regulation on a form and in a manner approved by the Commission as indicated in
				  the application.
B. A faculty
				  practice plan, a physician practice plan, a trauma center, or a trauma
				  physician that does not file an on-call services application within the time
				  frame specified is not eligible for participation in the Fund for that time
				  period.
C. An on-call services
				  application that is substantially incomplete or inaccurate may be considered
				  not filed.
Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 4 › Subtitle 25 - MARYLAND HEALTH CARE COMMISSION › Chapter 10.25.10 - Maryland Trauma Physician Services Fund › Section 10.25.10.13 - Audits

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Commission,
				  or its designee, may audit to verify the information submitted by faculty
				  practice plans, physician practice plans, trauma physicians, and trauma centers
				  applying for reimbursement from the Fund.
B. The Commission, or its designee, may
				  perform on-site audits.
C.
				  Information discovered by the audit process indicating that an application for
				  payment from the Fund was improperly paid may result in remedial action being
				  taken, including but not limited to, denial or partial denial of future
				  payments from the Fund, referral to the State of Maryland, Central Collections
				  Unit, or other appropriate action.