Md. Code Regs. 10.25.10.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.25.10.02 - Definitions

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

B. Terms Defined.

(1) "Applicant" means a person or entity eligible to file a claim to receive reimbursement from the Fund.

(2) "Commission" means the Maryland Health Care Commission.

(3) "Faculty practice plan" means a professional services organization that:

(a) Includes physicians; and

(b) Is formed to carry out, improve, and supplement the medical education, research, and clinical services program of a medical school.

(4) "Fraud" means knowingly and willfully making or causing to be made any false statement or representation of a material fact:

(a) In a claim for payment; or

(b) In determining eligibility for payments.

(5) "Fund" means the Maryland Trauma Physician Services Fund.

(6) "HSCRC" means the Health Services Cost Review Commission.

(7) "Maryland Trauma Registry" means a clinical trauma registry maintained by MIEMSS that:

(a) Monitors and provides information necessary to evaluate major trauma or specialty patient care, outcome, and cost; and

(b) Assesses how designated trauma centers and other hospitals comply with the trauma standards, regulations, and protocols.

(8) Medicaid.

(a) "Medicaid" means the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. § 1396, et seq. and the Children and Families Health Care Program under Title XXI of § 4901 of the Balanced Budget Act of 1997, that provide comprehensive medical and other health-related care for indigent and medically indigent persons.

(b) "Medicaid" includes the services provided by a managed care organization under the State waiver program authorized under § 1115 of the Social Security Act, 42 U.S.C. § 1396n.

(9) "Medicaid differential" means the difference in reimbursement between Medicare and Medicaid for trauma services provided by a trauma physician to a Medicaid trauma patient in a trauma center.

(10) "Medicare economic index (MEI)" means the federal Centers for Medicare and Medicaid Services' measure of inflation in the inputs for providing physician services.

(11) "MIEMSS" means the Maryland Institute for Emergency Medical Services Systems.

(12) On-Call Physician.

(a) "On-call physician" means a trauma physician who commits for a specific time period to be available and respond within a certain amount of time, as defined by MIEMSS, to provide care for a trauma patient in the trauma center.

(b) "On-call physician" does not include a physician on standby in a trauma center.

(13) On-Call Costs.

(a) "On-call costs" means the costs to a trauma center to have trauma physicians available and ready to respond to trauma patients within a certain amount of time, as defined by MIEMSS.

(b) "On-call costs" does not include standby costs.

(14) "On-call services application" means the Maryland Trauma Physician Services Fund semiannual on-call trauma services application, developed by the Commission.

(15) "Reasonable compensation equivalent(RCE)":

(a) Is a methodology established by Medicare to set limits on what a hospital may claim per physician specialty standby hour; and

(b) Has the meaning described in 68 FR 45458 (Aug. 1, 2003).

(16) Service Period.

(a) "Service period" means the time that trauma services are provided from entrance to the trauma center until dismissal or discharge from the trauma center.

(b) "Service period" includes a subsequent readmission or outpatient visit to the trauma center for services that are directly related to the initial trauma injury.

(17) "Specialty referral center" means:

(a) The Curtis National Hand Center at Union Memorial Hospital;

(b) The Eye Trauma Center at the Wilmer Eye Institute at The Johns Hopkins Hospital; and

(c) The Johns Hopkins Health System Burn Program.

(18) "Standby costs" means costs to a trauma center for paying physicians to be available on site at the trauma center to treat trauma patients.

(19) Trauma Center.

(a) "Trauma center" means a hospital designated by the Maryland Institute for Emergency Medical Services Systems(MIEMSS) as:

(i) The State primary adult resource center;

(ii) A Level I trauma center;

(iii) A Level II trauma center;

(iv) A Level III trauma center;

(v) A pediatric trauma center; or

(vi) A specialty referral center as defined in §B(17) of this regulation.

(b) "Trauma center" includes an out-of-State pediatric trauma center that has entered into an agreement with MIEMSS.

(20) "Trauma patient" means a patient whose trauma services are documented in the Maryland Trauma Registry.

(21) "Trauma physician" means a physician who provides trauma services during the service period to a trauma patient on the Maryland Trauma Registry as defined by the Maryland Institute for Emergency Medical Services Systems(MIEMSS).

(22) "Trauma services" means trauma care provided to a trauma patient in a trauma center, trauma-center-affiliated rehabilitation hospital, or rehabilitation unit of a trauma center.

(23) "Uncompensated care" means trauma services provided by a trauma physician to a trauma patient on the Maryland Trauma Registry who:

(a) Has no health insurance, including private health insurance, Medicare Part B coverage, VA health benefits, or CHAMPUS;

(b) Is not covered by Workers' Compensation coverage;

(c) Is not eligible for Medical Assistance coverage; and

(d) Has not paid the full Medicare reimbursement for the trauma care received, even after documented attempts by the trauma physician to obtain payment.

(24) "Uncompensated care shortfall" means the difference in reimbursement between what Medicare pays and what the trauma physician providing care collects from the uncompensated care trauma patient.

(25) "Uncompensated services claim" means a CMS 1500 form or an ANSI 837 electronic transaction completed according to Commission specifications and submitted for reimbursement of uncompensated care services.

Md. Code Regs. 10.25.10.02

Regulations .02 adopted as an emergency provision effective July 1, 2003 (30:19 Md. R. 1327); adopted permanently effective December 22, 2003 (30:25 Md. R. 1846)
Regulations .02 adopted as an emergency provision effective July 1, 2006 (33:21 Md. R. 1672); adopted permanently effective October 23, 2006 (33:21 Md. R. 1676)
Regulations .02 adopted effective June 15, 2009 (36:12 Md. R. 837)