.01 Definitions.

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 28.02.01.22.

(3) "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 10.09.24.15B and 10.09.25.14B; or

(c) Hospice provider under the hospice care program, in accordance with COMAR 10.09.35.

(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) "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.

(7) "Department" means the Maryland Department of Health, 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.

(8) "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.

(9) “Managed care" means the care manager's provision of comprehensive primary care and referral services to an enrollee in a managed care program.

(10) "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 10.09.24.15B or 10.09.25.14B; or

(d) Hospice care under COMAR 10.09.35.

(11) "Medical Assistance Program" means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.

(12) “Medical Care Programs" means the unit of the Department responsible for the administration of the Medical Assistance Program.

(13) "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 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, family, or provider.

(14) "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.

(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) "Primary care" means that medical care which addresses a patient's general health needs including the coordination of the patient's health care, with the responsibility for the prevention of disease, promotion and maintenance of health, treatment of illness, and referral to other specialists for more intensive care when appropriate.

(18) “Program" means the Medical Assistance Program.

(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.