Md. Code Regs. 10.67.06.03 - Benefits - Physician and Advanced Practice Nurse Specialty Care Services
A. An MCO shall
provide to its enrollees medically necessary specialty care services that are
outside of the enrollee's PCP's scope of practice, or, in the judgment of the
enrollee's PCP, are not services that the PCP customarily provides, is
specifically trained for, or is experienced in and are provided by:
(1) A physician or an advanced practice
nurse, acting within the scope of the individual's license or certification,
training, and experience;
(2) A
practitioner other than a physician or an advanced practice nurse when the
practitioner is in a physician's employ, is under the physician's direct
supervision, and performs the service within the scope of the practitioner's
license, certification, or other legal authorization, for the purpose of
assisting in the provision of the specialty care service;
(3) A clinic that furnishes health care
services by or under the direction of a physician; or
(4) For enrollees who are younger than 21
years old, a doctor of dental medicine or dental surgery, if the services are
surgical services that are also typically performed by physicians.
B. Notwithstanding §A(2) of
this regulation, specialty care services provided under Regulations .04-.25 of
this chapter may include medically necessary diagnostic and treatment services
provided by a physician or other appropriate practitioner, acting within the
scope of the practitioner's license, certification, or other legal
authorization, and in accordance with the practitioner's training and
experience.
Notes
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