Sec. 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 administrative services organization (ASO) 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 ASO to deny, reduce, terminate, delay, or suspend a covered service; and

(b) Governed by:

(i) COMAR 10.01.04; and

(ii) Any and all applicable court orders.

(5) "Administrative services organization (ASO)" means an organization with which MDH contracts to assist in the management of the dental program.

(6) "Benefits" means a schedule of dental services to be administered by the ASO to Medical Assistance participants pursuant to this chapter.

(7) "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.

(8) "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.

(9) "Covered services" means:

(a) All medically necessary dental services for Medical Assistance or State Children's Health Insurance Program (SCHIP) eligible children younger than 21 years old;

(b) Certain medically necessary dental services for pregnant women and REM participants 21 years old or older;

(c) Effective January 1, 2017, all medically necessary dental services for eligible former foster care participants younger than 26 years old; and

(d) Effective January 1, 2019, certain medically necessary services for dual-eligible participants 21 through 64 years old.

(10) "Dental benefits administrator" means an entity that administers 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.

(11) "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.

(12) "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., or the Department's designee.

(13) Dual Eligible.

(a) "Dual eligible" means an individual who is enrolled in both the Maryland Medical Assistance Program and Medicare.

(b) "Dual eligible" does not include Medicaid participants who only receive assistance with their Medicare premiums, deductibles, or copayments.

(14) "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.

(15) "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.

(16) "EPSDT certified provider" means a physician or nurse practitioner certified by the Department to provide EPSDT services.

(17) "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.

(18) "General supervision" has the meaning stated in COMAR 10.44.21 and 10.44.27.

(19) "Hospital" has the meaning stated in Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland.

(20) "Maryland Healthy Smiles Dental Program" means the Maryland Medicaid dental program that provides coverage for:

(a) Eligible children younger than 21 years old;

(b) Eligible pregnant women 21 years old or older;

(c) Eligible adults 21 years old or older enrolled in the Rare and Expensive Case Management (REM) program;

(d) Eligible former foster care participants younger than 26 years old; and

(e) Eligible participants who are:

(i) Dual eligible; and

(ii) 21 through 64 years old.

(21) "Medical Assistance Program" means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.

(22) "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.

(23) "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.

(24) "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.

(25) "Network provider" means a health care entity or health care professional that is either employed by, or has executed a provider agreement with, the dental benefits administrator, or its subcontractor to render covered services to the participant.

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

(27) "Preauthorization" means an approval required from the Department or its designee before the provision of dental or oral health care services.

(28) "Primary dental office" means the dental care provider responsible for coordinating, integrating, and providing dental care for the participant.

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

(30) "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.

(31) "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.

(32) "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.

(33) "Self–ligating braces" means braces which utilize a permanently installed, moveable component to secure the archwire without the use of ligatures.