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<regulation prefix="Regulation" num=".02" citation="COMAR 10.25.09.02" title_num="10" subtitle_num="25" chapter_num="09" heading="Definitions.">
  <paragraph num="A.">
    <text>In this chapter, the following terms have the meanings indicated.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Terms Defined.</text>
    <paragraph num="(1)">
      <text>“Adjudication” means paid, resolved, or settled.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>“Commission” or “MHCC” means the Maryland Health Care Commission.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>“HIPAA” means the Health Insurance Portability and Accountability Act of 1996, P.L. No. 104 — 191, 42 U.S.C. Title XI, Part C.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>“Deputy Director” means the Deputy Director for Data Systems and Analysis at the Maryland Health Care Commission, or the Deputy Director's designee.</text>
    </paragraph>
    <paragraph num="(5)">
      <text>“Designate” means to select and to enter into a written agreement with.</text>
    </paragraph>
    <paragraph num="(6)">
      <text>“Designated EHNs” means MHCC-certified EHNs that have been selected by a payer to submit electronic health care transactions under a written service agreement with the payer on behalf of health care practitioners.</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Electronic health care transactions" means health care transactions that are defined under HIPAA Transaction and Code Set Standards.</text>
    </paragraph>
    <paragraph num="(8)">
      <text>“Electronic health network (EHN)” means an entity that processes or facilitates processing of electronic transactions in standard or nonstandard formats, between two or more trading partners in the health care community.</text>
    </paragraph>
    <paragraph num="(9)">
      <text>“MHCC-certified electronic health network” means an entity that has received certifications from the Maryland Health Care Commission.</text>
    </paragraph>
    <paragraph num="(10)">
      <text>“Health insurance claim” means a submission of a claim to a third-party payer for payment for services rendered by a health care practitioner in Maryland.</text>
    </paragraph>
    <paragraph num="(11)">
      <text>“Third-party payer” or “payer” means a person that administers or provides reimbursement for health care benefits on an expense-incurred basis, including a:</text>
      <paragraph num="(a)">
        <text>Health maintenance organization issued a certificate of authority in accordance with Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Health insurer or nonprofit health service plan authorized to offer health insurance policies or contracts in this State in accordance with Insurance Article, Title 14, Annotated Code of Maryland;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Third-party administrator registered under Insurance Article, Title 14, Annotated Code of Maryland;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Specialty payers, such as Pharmacy Benefit Managers (PBMs); or</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Managed Care Organizations (MCOs) which contract with Maryland Medicaid to provide health services to Medicaid enrollees.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>