Md. Code Regs. 10.09.05.01 - Definitions
A. In this chapter,
the following terms have the meanings indicated.
B. Terms Defined.
(1) "Adverse action" means any action taken
by the dental benefits administrator (DBA) to deny, reduce, terminate, delay,
or suspend a covered service.
(2)
"Aftercare" means the period of follow-up care after initial services are
rendered, during which any additional related services rendered by the same
provider are included in the payment for the original services.
(3) "Ambulatory surgical center (ASC)" means
any Medicare-certified entity that operates exclusively for the purpose of
providing surgical services to patients not requiring
hospitalization.
(4) "Appeal" means
the process:
(a) To resolve a participant's
dispute with any adverse action taken by the DBA to deny, reduce, terminate,
delay, or suspend a covered service; and
(5)
"Benefits" means a schedule of dental services to be administered by the DBA to
Medical Assistance participants pursuant to this chapter.
(6) "Claim" means an itemized statement
requesting payment for services rendered by health care providers, such as
dentists, billed:
(a)
Electronically;
(b) Through a
web-based portal; or
(c) Manually
on the American Dental Association (ADA) claim form.
(7) "Consultation" means written opinion or
advice rendered by a dentist, upon request by the patient's attending physician
or dentist, for the further evaluation or management of the patient by the
attending physician or dentist. If the consultant dentist assumes
responsibility for the continuing care of the patient, a subsequent service
rendered by the consultant is not a consultation.
(8) "Dental benefits administrator (DBA)" means an
entity with which the Department contracts to administer dental benefits by
performing some or all of the following functions:
(a) General administration;
(b) Regulatory compliance;
(c) Network administration;
(d) Member services;
(e) Claims administration;
(f) Data reporting and analysis;
(g) Medical management; or
(h) Quality monitoring.
(9) "Dental services" means emergency,
preventive, or therapeutic services for oral diseases which are administered by
or under the general supervision of a dentist in the practice of the
profession.
(10) "Department" means
the State Department of Health and Mental Hygiene, 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., or the Department's
designee.
(11) "Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT)" means comprehensive and preventive
health care pursuant to 42
U.S.C. §
1396d(e) as
amended by OBRA 1989.
(12)
"Emergency services" means services necessary for the treatment of any
condition requiring immediate attention for the relief of pain, hemorrhage,
acute infection, or traumatic injury to the teeth, supporting structures (that
is, periodontal membranes, gums, and alveolar bone), the jaws, and tissues of
the oral cavity.
(13) "EPSDT
certified provider" means a physician, physician assistant, or nurse
practitioner certified by the Department to provide EPSDT services.
(14) "Free-standing clinic" means a health
care facility approved for participation in the Maryland Medical Assistance
Program that is not licensed as a hospital or as part of a hospital or nursing
home and that is not administratively part of a health maintenance organization
or physician's, dentist's, or osteopath's office, but which has a separate
staff functioning under the direction of the clinic administrator (as defined
in 42 CFR §
405.1801) or a health officer and which is
organized and operated to provide clinic services.
(16) "Hospital" has the meaning stated in
Health-General Article, Title 19, Subtitle 3, Annotated Code of
Maryland.
(17) "Maryland Healthy
Smiles Dental Program" means the Maryland Medicaid dental program.
(18) "Medical Assistance Program" means the
program of comprehensive medical and other health-related care for indigent and
medically indigent persons.
(19)
"Medically necessary" means that a 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, dental practice, or both;
(c) The most cost effective 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.
(20) "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.
(21) "Mobile dental unit" means any
self-contained facility in which dentistry will be practiced and which may be
moved, towed, or transported from one location to another.
(22) "Network provider" means a health care entity or
health care professional that has executed a provider agreement with Maryland
Medicaid.
(23) "Participant" means
an individual who is certified as eligible for, and is receiving, Medical
Assistance benefits.
(24)
"Preauthorization" means an approval required from the Department or its
designee before the provision of dental or oral health care services.
(25) "Primary dental office" means the fixed
and permanent location where the mobile dental unit:
(a) Is linked through either ownership or a
legally binding contract; and
(b)
Transmits participant records.
(26) "Program" means the Maryland Medical
Assistance Program.
(27) "Provider"
means:
(a) An individual dentist, duly
licensed to provide services for participants, or an association, partnership,
or an incorporated or unincorporated group of dentists so licensed, that,
through appropriate agreement with the Department, has been identified as a
Program provider by the issuance of an individual account number; or
(b) An approved dental school whose students
are permitted under Health Occupations Article, §
4-301(b)(1),
Annotated Code of Maryland, to treat dental patients and which, through
appropriate agreement with the Department, has been identified as a Program
provider by issuance of an individual account number.
(28) "Referral" means a transfer of the
patient from a physician or dentist to a dentist for diagnosis and treatment of
the condition for which the referral was made. The dentist to whom the referral
is made will no longer be considered the consultant.
(29) "REM" means the fee-for-service managed
care program for individuals who have certain rare and expensive health care
conditions set forth in COMAR 10.09.69.
(30) "Self-ligating braces" means braces
which utilize a permanently installed, moveable component to secure the
archwire without the use of ligatures.
(31) "Traditional comprehensive orthodontic
treatment" means a coordinated diagnosis and treatment to improve craniofacial
dysfunction or dentofacial deformity which may utilize fixed and removable
orthodontic appliances and focus on specific objectives at various stages of
dentofacial development.
Notes
Regulations .01I amended as an emergency provision effective February 1, 1982 (9:2 Md. R. 110); emergency status extended at 9:11 Md. R. 1122 and 9:17 Md. R. 1697 (Emergency provisions are temporary and are not printed in COMAR)
Regulations .01 amended as an emergency provision effective December 2, 1992 (19:26 Md. R. 2282); amended permanently effective June 1, 1993 (20:10 Md. R. 851)
Regulation .01B amended effective October 1, 1985 (12:19 Md. R. 1848); August 27, 2007 (34:17 Md. R. 1507); May 19, 2008 (35:10 Md. R. 972)
Regulation .01B amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
Regulation .01B amended effective December 27, 2010 (37:26 Md. R. 1787)
Regulation .01 amended effective 42:6 Md. R. 511, eff.
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