10.09.02.01

.01 Definitions.

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 Maryland Department of Health, 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 10.09.70.10C 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) "Patient" means a recipient awaiting or undergoing health care or treatment.

(17) "Physician" means an individual legally licensed to practice medicine by the Board or in the state in which the physician's practice is located.

(18) "Preauthorization" means an approval required from the Department or its designee before services can be rendered.

(19) "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.

(20) "Prescriber" means a physician, dentist, podiatrist, or other professional authorized to prescribe legend drugs and authorized by the Department to participate in the Program.

(21) "Prescription" means a written order for medication, or medical supplies or equipment, signed by the prescriber.

(22) "Program" means the Maryland Medical Assistance Program.

(23) "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.

(24) "Recipient" means a person who is certified as eligible for, and is receiving, Medical Assistance benefits.

(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.