10.09.82.01

.01 Definitions.

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Department" means the Maryland Department of Health, the single State agency designated to administer the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

(2) “Healthcare Common Procedure Coding System (HCPCS)” means a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).

(3) "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.

(4) "Medicare-certified facility" means a facility which is certified for Medicare by the regional office of the Centers for Medicare and Medicaid Services (CMS).

(5) “Provider-based outpatient oncology facility” means an outpatient facility that is:

(a) Owned by a hospital;

(b) Located off-site from the hospital; and

(c) Not regulated by the Health Services Cost Review Commission (HSCRC).

(6) "Recipient" means an individual who is certified as eligible for, and is receiving, Medical Assistance benefits.