reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51490.1 - Claim Submission Requirements for Counties and Providers of Drug Medi-Cal Substance Use Disorder Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Claims from counties and providers for
					 reimbursement of outpatient drug free, day care habilitative, narcotic
					 treatment program, Naltrexone treatment, and perinatal residential treatment
					 services shall be presented to the Department no later than six (6) months from
					 the date of service, unless the county or provider has good cause, as specified
					 in Sections
					 51008 and
					 51008.5. The county or provider
					 shall produce, upon request by the Department for audit or monitoring purposes,
					 documentation to substantiate the good cause.
(b) An additional unit of service, or a
					 multiple service billing, provided to a beneficiary on the same day may be
					 claimed up to the maximum amount allowable if the beneficiary's return visit is
					 to the same provider and the return visit service is not a duplicate to, or the
					 same as, the service previously provided to the beneficiary on the same day.
"Multiple billing" means a claim is being made for a
						return, face-to-face visit, which is for an additional service to a previously
						provided service on that same day. The county and/or provider shall prepare and
						retain, in the beneficiary's patient record, a Multiple Billing Override
						Certification (Form DHCS MC 6700 (Revised 6/2014)), hereby incorporated by
						reference, certifying that a review of the client's record substantiated the
						multiple service. The form shall be signed by the person authorized to
						represent the county and/or provider.
(1) For outpatient drug free and Naltrexone
					 treatment services:
(A) The return visit
					 shall not create a hardship on the beneficiary; and
(B) The return visit shall be clearly
					 documented in the beneficiary's progress notes with the time of day each visit
					 was made. The progress notes shall clearly reflect that an effort was made to
					 provide all necessary services during one visit and the return visit was
					 unavoidable; or,
(C) The return
					 visit shall be a crisis or collateral service. Collateral services shall be
					 documented in the beneficiary's treatment plan in accordance with the
					 beneficiary's short/long-term goals. The beneficiary's progress notes shall
					 specifically reflect the steps taken to meet the goals defined in the
					 beneficiary's treatment plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51491 - Local Educational Agency (LEA) Eligibility for Payment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Reimbursement for LEA Services shall be limited to those
						services provided to an LEA Eligible Beneficiary, by an LEA Practitioner,
						through an LEA Provider.
(a) LEA
					 health and mental health evaluation and health and mental health education
					 services shall be reimbursable only if those services are provided by an LEA
					 Practitioner who:
(1) If licensed or certified
					 under the Business and Professions Code, Healing Arts Division, Section
					 500 et seq., furnishes LEA
					 Services within the scope of practice of the practitioner as defined in that
					 code;
(2) If not licensed or
					 certified under the Business and Professions Code, Healing Arts Division,
					 furnishes LEA Services within the following limitations:
(A) A credentialed school psychologist
					 meeting the qualifications defined in Education Code, Section
					 49422, may
					 provide psychosocial assessments, and health education and anticipatory
					 guidance only;
(B) A credentialed
					 school social worker meeting the qualifications defined in Education Code,
					 Section
					 44874, may
					 provide psychosocial assessments and health education and anticipatory guidance
					 only;
(C) A credentialed school
					 counselor meeting the qualifications defined in Education Code, Section
					 49600, may
					 provide psychosocial assessments only;
(D) A registered school audiometrist
					 registered pursuant to Health and Safety Code, Sections
					 1685
					 and
					 1686
					 may provide hearing assessments only;
(E) A registered credentialed school nurse
					 meeting the qualifications defined in Education Code, Sections
					 49426 and
					 44877, may
					 provide vision, hearing, developmental, and psychological assessments, health
					 education and anticipatory guidance, and nutritional assessments and nutrition
					 education. Registered credentialed school nurses may provide hearing
					 assessments only if they are a registered school audiometrist.
(F) A credentialed language, speech and
					 hearing specialist meeting the qualifications defined in Education Code,
					 Sections
					 44225(b)(4)
					 and
					 44268 may
					 perform hearing assessments and developmental assessments related to language
					 only.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51492 - Claim Submission Requirements for Targeted Case Management Providers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Only local
					 governmental agencies meeting the eligibility criteria specified in Section
					 51271 shall submit targeted case
					 management service claims to the department.
(b) All claims for targeted case management
					 services provided to Medi-Cal beneficiaries by a targeted case management
					 services provider pursuant to Welfare and Institutions Code, Section
					 14132.44,
					 shall be submitted electronically to the department. The electronic submission
					 may be magnetic tape or diskette.
(c) Each electronically submitted claim shall
					 be accompanied by a corresponding invoice.
(d) Claims for targeted case management
					 services may be submitted monthly, but not more than six months after the month
					 in which the targeted case management service is rendered pursuant to Welfare
					 and Institutions Code, Section
					 14115.
1. New
						section filed 7-1-96; operative 7-1-96. Submitted to OAL for printing only
						pursuant to Section
						6, Chapter 305, Statutes of 1995
						(Register 96, No. 27).
2. New section refiled 10-29-96 as an
						emergency; operative 10-29-96 (Register 96, No. 44). Submitted to OAL for
						printing only pursuant to Section
						6, Chapter 305, Statutes of 1995.
						A Certificate of Compliance must be transmitted to OAL by 2-26-97 or emergency
						language will be repealed by operation of law on the following
						day.
3. Editorial correction of HISTORY 2 (Register 97, No.
						15).
4. Repealed by operation of Government Code section
						11346.1(g)
						(Register 97, No. 15).
5. New section filed 4-10-97; operative
						4-10-97 pursuant to Government Code section
						11343.4(d)
						(Register 97, No. 15).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14132.44,
						  Welfare and Institutions Code. Reference: Section
						  14132.44,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51492.1 - Host County Contractual Responsibilities in the Targeted Case Management Program. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-1-96; operative 7-1-96. Submitted to OAL for printing only
						pursuant to Section
						6, Chapter 305, Statutes of 1995
						(Register 96, No. 27).
2. New section refiled 10-29-96 as an
						emergency; operative 10-29-96 (Register 96, No. 44). Submitted to OAL for
						printing only pursuant to Section
						6, Chapter 305, Statutes of 1995.
						A Certificate of Compliance must be transmitted to OAL by 2-26-97 or emergency
						language will be repealed by operation of law on the following
						day.
3. Editorial correction of HISTORY 2 (Register 97, No.
						15).
4. Repealer filed 4-10-97; operative 4-10-97 pursuant to
						Government Code section
						11343.4(d)
						(Register 97, No. 15).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14132.44,
						  Welfare and Institutions Code. Reference: Section
						  14132.44,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51492.2 - Participation Fee Requirements in the Targeted Case Management Program

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The department
					 shall perform administrative activities, including technical support,
					 processing claims, and program monitoring for local governmental agencies
					 participating in the targeted case management program, pursuant to Welfare and
					 Institutions Code, Section
					 14132.44.
(b) Local governmental agencies shall pay the
					 department's costs of performing administrative activities described in
					 subsection (a).
(c) Local
					 governmental agencies shall designate a host county as defined in Section
					 51185(c). Each
					 participating local governmental agency shall deposit with the host county an
					 annual participation fee, for that local governmental agency's portion of the
					 costs described in subsection (b), through a mechanism agreed to by the
					 department and local governmental agencies.
1. New
						section filed 7-1-96; operative 7-1-96. Submitted to OAL for printing only
						pursuant to Section
						6, Chapter 305, Statutes of 1995
						(Register 96, No. 27).
2. New section refiled 10-29-96 as an
						emergency; operative 10-29-96 (Register 96, No. 44). Submitted to OAL for
						printing only pursuant to Section
						6, Chapter 305, Statutes of 1995.
						A Certificate of Compliance must be transmitted to OAL by 2-26-97 or emergency
						language will be repealed by operation of law on the following
						day.
3. Editorial correction of HISTORY 2 (Register 97, No.
						15).
4. Repealed by operation of Government Code section
						11346.1(g)
						(Register 97, No. 15).
5. New section filed 4-10-97; operative
						4-10-97 pursuant to Government Code section
						11343.4(d)
						(Register 97, No. 15).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14132.44,
						  Welfare and Institutions Code. Reference: Section
						  14132.44,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51501 - General

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Notwithstanding
					 any other provisions of these regulations, no provider shall charge for any
					 service or any article more than would have been charged for the same service
					 or article to other purchasers of comparable services or articles under
					 comparable circumstances. However, if an organized outpatient clinic renders
					 services without charge to the general public under programs, other than Title
					 XVIII or XIX, financed by federal or state funds, Medi-Cal may be considered a
					 third party payor and be billed for Medi-Cal covered services when rendered to
					 Medi-Cal beneficiaries if:
(1) The clinic has
					 an established fee schedule; and
(2) The clinic ascertains from all
					 individuals served whether they have a third party coverage for medical care or
					 services, and if such coverage is available that third party coverage is billed
					 and a diligent effort made to collect such claimed amounts; and
(3) Medi-Cal is not the only third party pay
					 or from which the clinic seeks payment.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51502.1 - Requirements for Electronic Claims Submission

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) As used in this section, the following
					 definitions shall apply:
(1) "Biller"
					 includes any employee, officer, agent or director of the entity which will bill
					 on behalf of a provider pursuant to a contractual relationship with the
					 provider which does not include payment to billers on the basis of a percentage
					 of amount billed or collected from Medi-Cal.
(2) "Source Documents" include every document
					 or record on which the provider or the biller relies to submit a claim, as
					 described in Title 22, Section
					 51476. Source documents shall also
					 include all printed representations of information transmitted as a claim to
					 the biller or the fiscal intermediary, whether transmitted by the provider or
					 biller.
(3) "Provider" shall have
					 the same meaning as in Section
					 51051 of these
					 regulations.
(4) "Electronic claims
					 submission" means that submission of Medi-Cal claims for service on magnetic
					 tape, computer-to-computer via telephone or other electronic means which are
					 approved by the Director as being compatible with and acceptable for processing
					 by the State claims processing system.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51503 - Physician Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Except as otherwise provided, reimbursement for physician services shall be the
					 usual charges made to the general public not to exceed the maximum
					 reimbursement rates listed in this section for each procedure performed by a
					 physician.
(b) Except as set forth
					 in (d), (e), (h), (k) and (
l
), the maximum reimbursement rates
					 for physician services shall be the rates set forth in the "Schedule of
					 Medi-Cal Physician Rates", published by the Department of Health Services, June
					 2002, herein incorporated by reference in its entirety.
(c) As used in (b), a given procedure listed
					 in the "Schedule of Medi-Cal Physician Rates" means those procedures which are
					 a benefit of the Medi-Cal program as determined by the Department.
(d) The maximum reimbursement for "By Report"
					 procedures, and procedures not listed in the "Schedule of Medi-Cal Physician
					 Rates" shall be based upon a review of such procedures to determine their
					 relationship to other procedures for which reimbursement rates are
					 established.
(e) The maximum
					 reimbursement rate for professional services for immunizations shall be $9.00.
					 The maximum reimbursement rate for professional services for other injections
					 shall be $4.46.
(f) Maximum
					 reimbursement rates for anesthesia services shall be determined in accordance
					 with this Section, except anesthesia services performed by a nurse anesthetist
					 and billed by a physician shall be reimbursed in accordance with Section
					 51505.2. Physicians billing for
					 anesthesia services performed by a nurse anesthetist shall indicate on the
					 claim that such services were performed by a nurse anesthetist.
(g) Reimbursement for services rendered on or
					 after November 1, 1976 by physicians which were provided in hospital outpatient
					 emergency, examining, and treatment rooms shall be reduced to 80 percent of the
					 maximum reimbursement rates as set forth in (b) unless:
(1) The physician is called from outside the
					 outpatient department setting to provide emergency services.
(2) The physician or group of physicians
					 contract with a hospital and assume total financial responsibility for such
					 outpatient services.
(3) Specified
					 medical procedures, as determined by the Department, when performed in a
					 hospital outpatient setting may be reimbursed at the rates set forth in
					 (b).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51503.1 - Reimbursement for Services Rendered by a Nonphysician Medical Practitioner

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Except as
					 provided in (b), reimbursement for services rendered by a nonphysician medical
					 practitioner shall be made directly to the physician, organized outpatient
					 clinic or hospital outpatient department utilizing the nonphysician medical
					 practitioner.
(b) Reimbursement for
					 services rendered by a nurse midwife, a certified family nurse practitioner, or
					 a certified pediatric nurse practitioner shall be made in accordance with
					 Section 51503.2.
(c) Reimbursement shall be the lesser of the
					 billed amount or the rates established pursuant to Section
					 51503.
(d) All claims for payment for nonphysician
					 medical practitioner services rendered pursuant to (a) shall include:
(1) The name and license or certificate
					 number of the nonphysician medical practitioner rendering the
					 service.
(2) The location at which
					 the service was rendered.
(3) The
					 name of the supervising physician or the attending
					 physician.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51503.2 - Reimbursement for Services Rendered by a Nurse Midwife, a Certified Family Nurse Practitioner, or a Certified Pediatric Nurse Practitioner

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement
					 for services rendered by a nurse midwife, a certified family nurse
					 practitioner, or a certified pediatric nurse practitioner shall be the usual
					 charges made to the general public not to exceed the maximum reimbursement
					 rates established in Section
					 51503 for the same
					 service.
(b) Reimbursement may be
					 made either:
(1) Directly to the nurse
					 midwife, a certified family nurse practitioner, or certified pediatric nurse
					 practitioner as an independent provider of service.
(2) To the physician, organized outpatient
					 clinic, or hospital outpatient department which employs or utilizes the nurse
					 midwife, a certified family nurse practitioner, or certified pediatric nurse
					 practitioner as a nonphysician medical practitioner in accordance with Section
					 51503.1.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51503.3 - Reimbursement for Sign Language Interpreter Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement for the provision of sign
					 language interpreter services utilized in accordance with Section
					 51309.5, rendered by non-certified
					 or certified interpreters shall be made to Medi-Cal enrolled providers
					 employing fewer than fifteen employees in accordance with the maximum
					 reimbursement rates set forth in this section. However, in no case shall the
					 services billed exceed charges made to the general public for provision of
					 similar services.
(b) Reimbursement
					 for sign language interpreter services shall be as follows:
Procedure
								Code
Description
Rate
Z0324
Certified Sign Language
								Interpreter
$64.55
Z0326
Non-Certified Sign
								Language Interpreter
$38.73
Each procedure code represents a minimum of two hours of
						service, which includes travel time.
(c) Additional sign language interpreter
					 services may be billed in 15-minute increments as follows:
Z0328
Certified Sign Language
								Interpreter
$6.36
Z0329
Non-Certified Sign Language
								Interpreter
$3.82
1. New
						section filed 8-21-2000 as an emergency; operative 8-21-2000 (Register
						2000,
						No. 34). A Certificate of Compliance must be transmitted to OAL by 12-19-2000
						or emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 8-21-2000 order transmitted
						to OAL 12-19-2000 and filed 2-2-2001 (Register 2001, No. 5).
3.
						Amendment of subsection (a) and NOTE filed 8-7-2008; operative 9-6-2008
						(Register 2008, No. 32).
Note: Authority cited: Section
						  20, Health and Safety Code; and
						  Sections
						  10725
						  and
						  14105,
						  Welfare and Institutions Code. Reference: Section
						  54.1, Civil
						  Code; Section
						  14000,
						  Welfare and Institutions Code;
						  42 USC Sections
						  12101 et seq.;
						  28 CFR Section
						  36.303; and
						  45 CFR Section
						  84.22(c).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51504 - Comprehensive Perinatal Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Except where a capitated health system
					 contract entered into by the Department provides otherwise, reimbursement for
					 comprehensive perinatal obstetric, nutrition, psychosocial, and health
					 education services shall be made only to comprehensive perinatal providers
					 defined in Section
					 51179.1.
(b) Except where a capitated health system
					 contract entered into by the Department provides otherwise, reimbursement for
					 comprehensive perinatal obstetric services shall not exceed the maximum
					 allowances for similar services established in Sections
					 51503,
					 51509 or
					 51509.1, whichever is applicable,
					 plus the following amounts.
(1) An additional
					 $50.00 shall be allowed for the initial comprehensive medical office visit when
					 provided within 16 weeks of the last menstrual period.
(2) An additional $100.00 in total shall be
					 allowed for the tenth and all subsequent prenatal office
					 visits.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51504.1 - Reimbursement for Services Rendered by a Licensed Midwife

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement for services rendered by a
					 licensed midwife shall be the usual charges made to the general public not to
					 exceed the maximum reimbursement rates listed in Section
					 51503 for the same
					 service.
(b) Reimbursement shall be
					 made directly to the licensed physician and surgeon, clinic licensed pursuant
					 to Sections
					 1204
					 or
					 1204.3
					 of the Health and Safety Code, or a clinic exempt from licensure under Section
					 1206
					 of the Health and Safety Code that utilizes the licensed midwife's
					 services.
(c) Each claim for
					 licensed midwife services shall be submitted by the licensed physician and
					 surgeon, clinic licensed pursuant to Sections
					 1204
					 or
					 1204.3
					 of the Health and Safety Codes, or a clinic exempt from licensure under Section
					 1206
					 of the Health and Safety Codes, and shall include the name and Medi-Cal
					 provider number of each licensed midwife and licensed physician and surgeon who
					 supervised the provision of services for which reimbursement is being
					 claimed.
1. New
						section filed 9-3-2004; operative 10-3-2004 (Register 2004, No.
						36).
Note: Authority cited: Section
						  14105,
						  Welfare and Institutions Code. Reference: Section
						  14132.39,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51505 - Other Professional Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 11-1-76 as an emergency; effective upon filing (Register 76,
						No. 45). For prior history, see Register 75, No. 32.
2. Amendment of
						subsection (b) filed 12-14-76; effective thirtieth day thereafter (Register 76,
						No. 51).
3. Certificate of Compliance filed 1-28-77 (Register 77,
						No. 5).
4. Repealer filed 11-4-77; effective thirtieth day
						thereafter (Register 77, No. 45).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51505.3 - Psychology Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Reimbursement for psychology services shall be the usual charges made to the
					 general public not to exceed the maximum reimbursement allowances listed in
					 this section.
(b) Group therapy
					 shall be counseling at least two but not more than eight persons at any
					 session. Group therapy reimbursement shall not be made for sessions which are
					 less than one and one-half hours.
(c) Family therapy shall include at least two
					 members of the immediate family, as defined by subsection (c) of Section
					 51466. The oldest family member in
					 attendance shall be billed under procedure codes X9508 or X9510. All other
					 family members in attendance shall be billed under procedure code X9512. For
					 Medi-Cal clients:
(1) A MEDI label and
					 Medi-Cal claim form shall be submitted for each Medi-Cal eligible family member
					 in attendance at the family therapy session.
(2) At least two Medi-Cal eligible family
					 members shall be in attendance at the family therapy session.
(3) At least one Medi-Cal eligible family
					 member shall be billed under procedure code X9512 for each family therapy
					 session.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51506 - Dental Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 reimbursement for dental services shall be in accordance with the maximum
					 reimbursement rates listed below. Billing shall not exceed charges made to the
					 general public.
(1) Maximum reimbursement
					 rates include preparation of necessary forms to cover dental services and
					 appliances as prescribed.
(2) A
					 treatment plan authorized for a beneficiary 17 years of age or younger shall be
					 effective until completion if there is both continuing eligibility and dental
					 necessity, regardless of change in age status.
(3) The maximum reimbursement for By Report
					 (B/R) procedures shall be based upon a review of such procedures to determine
					 their relationship to other procedures for which a maximum reimbursement rate
					 has been established.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51507 - Physical Therapy

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Reimbursement for physical therapy services shall be the usual charges made to
					 the general public not to exceed the maximum reimbursement rates listed in this
					 section.
(b) The following
					 definitions shall apply to the reimbursement of physical therapy services under
					 this section.
(1) Modality means any physical
					 therapy treatment, unless listed separately which does not require the
					 continuous attention of the therapist. Examples are:
a.
Hot or cold
								packs
f.
Microwave
b.
Traction,
								mechanical
g.
Whirlpool
c.
Electrical
								stimulation
h.
Diathermy
(unattended)
i.
Infrared
d.
Vasopneumatic
								devices
j.
Ultraviolet
e.
Paraffin
								bath
k.
Ultrasound
(2) Procedure means any physical therapy
					 treatment, unless listed separately which requires the continuous attention of
					 the therapist. Examples are:
a.
Therapeutic
								exercise
h.
Electrical stimulation
b.
Neuromuscular reeducation
(motor
								point)
c.
Rehabilitation
								services
i.
Ionotophoresis
d.
Functional
								activities
j.
Traction, manual
e.
Gait
								training
k.
Massage
f.
Orthotics
								training
l
.
Contrast baths
g.
Prosthetics training
(3) Tests and measurements mean individually
					 administered, observed and recorded procedures and include a written report of
					 the tests and measurements involved. Examples are:
a.
Orthotic "check
								out"
c.
Activities of daily living
b.
Prosthetic "check out"
"check
								out"
(4) Case Conference means participation in
					 organized conference with other health team members, who are immediately
					 involved in the care or recovery of the patient, concerning status, or
					 progress, of the patient under treatment and includes required charting
					 entries. Case conferences shall be limited to one per patient per
					 month.
(5) Additional 15-minute
					 period means any 15-minute period or major portion thereof, 7 minutes or more,
					 immediately following the initial 30 minutes.
(6) The maximum allowance for home or
					 long-term care facility visit is payable only for visits to the first patient
					 receiving services at any given location on the same day.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51507.1 - Occupational Therapy

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Reimbursement for occupational therapy services shall be the usual charges made
					 to the general public not to exceed the maximum reimbursement rates listed in
					 this section.
(b) The following
					 definitions shall apply to the reimbursement of occupational services under
					 this section:
(1) Treatment means therapeutic
					 procedures which require the personal attention or direct supervision of the
					 therapist.
(2) Evaluation means
					 initial or subsequent evaluation using tests, measurements, and observation of
					 the patient's performance, progress, and behavior, and includes written reports
					 thereof.
(3) Case conference means
					 participation in organized conference with other health team members, who are
					 immediately involved in the care or recovery of the patient, concerning status
					 or progress of the patient under treatment and includes required charting
					 entries. Case conferences shall be limited to one per patient per
					 month.
(4) Additional 15-minute
					 periods means any 15-minute period or a major portion thereof, 7 minutes or
					 more, following the initial 30-minute period.
(5) The maximum allowance for home or
					 long-term care facility visit is payable only for visits to the first patient
					 receiving services at any given location on the same day.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51507.3 - Respiratory Care Practitioner

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement for respiratory care
					 services shall be the usual charges made to the general public not to exceed
					 the maximum reimbursement rates authorized by this section.
(b) Reimbursement for all equipment used in
					 respiratory care practitioner services shall be made only to durable medical
					 equipment dealers in accordance with Section
					 51521. No separate reimbursement
					 shall be made to a respiratory care practitioner for installation, setup, or
					 instruction in the use of equipment.
(c) Maximum reimbursement rates for
					 respiratory care practitioner services shall be as established in Section
					 51503, except that:
(1) No reimbursement shall be allowed to
					 respiratory care practitioners for physician interpretation or evaluation
					 services, and;
(2) The maximum
					 reimbursement rates for a respiratory care evaluation and a respiratory care
					 case conference shall be as follows:
Code
Maximum
Number
Allowances
X4700
Evaluation
$29.48
X4702
Case
								conference
17.93
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508 - Hospital Inpatient Services Reimbursement. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 9-1-77; effective thirtieth day thereafter (Register 77, No.
						36). For prior history, see Register 76, No. 38.
2. Amendment of
						subsections (a)(1) and (a)(3) filed 2-5-79; effective thirtieth day thereafter
						(Register 79, No. 6).
3. Amendment of subsections (a)(1) and (a)(3)
						filed 8-1-79; effective thirtieth day thereafter (Register 79, No.
						31).
4. Repealer filed 5-30-80; designated effective 1-1-80
						(Register 80, No. 29).
Note: Authority cited: Sections
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.1 - Extraordinary Administrative Adjustments. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-2-76 as an emergency; effective upon filing. Certificate of
						Compliance included (Register 76, No. 23).
2. Repealer filed
						5-30-80; designated effective 1-1-80 (Register 80, No.
						29).
Note: Authority cited: Sections
						  14100,
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14100,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.2 - Definitions. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-2-76 as an emergency; effective upon filing. Certificate of
						Compliance included (Register 76, No. 23).
2. Repealer filed
						5-30-80; designated effective 1-1-80 (Register 80, No.
						29).
Note: Authority cited: Sections
						  14100,
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14100,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.3 - Application. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-2-76 as an emergency; effective upon filing. Certificate of
						Compliance included (Register 76, No. 23).
2. Repealer filed
						5-30-80; designated effective 1-1-80 (Register 80, No.
						29).
Note: Authority cited: Sections
						  14100,
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14100,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.4 - Review of Application. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-2-76 as an emergency; effective upon filing. Certificate of
						Compliance included (Register 76, No. 23).
2. Repealer filed
						5-30-80; designated effective 7-1-80 (Register 80, No.
						29).
Note: Authority cited: Sections
						  14100,
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14100,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.5 - Criteria for Review. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-2-76 as an emergency; effective upon filing. Certificate of
						Compliance included (Register 76, No. 23).
2. Amendment of
						subsection (a)(2) filed 5-20-77; effective thirtieth day thereafter (Register
						77, No. 21).
3. New subsection (a)(2)(C) filed 2-8-78; effective
						thirtieth day thereafter (Register 78, No. 6).
4. New subsection
						(a)(2)(D) filed 2-5-79; effective thirtieth day thereafter (Register 79, No.
						6).
5. New subsection (a)(2)(E) filed 8-1-79; effective thirtieth
						day thereafter (Register 79, No. 31).
6. Repealer filed 5-30-80;
						designated effective 7-1-80 (Register 80, No.
						29).
Note: Authority cited: Sections
						  14100,
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14100,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.6 - Recommendation. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-2-76 as an emergency; effective upon filing. Certificate of
						Compliance included (Register 76, No. 23).
2. Repealer filed
						5-30-80; designated effective 7-1-80 (Register 80, No. 29).
3.
						Editorial correction of NOTE (Register 97, No.
						31).
Note: Authority cited: Sections
						  14100,
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14100,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.7 - Action by the Director. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-2-76 as an emergency; effective upon filing. Certificate of
						Compliance included (Register 76, No. 23).
2. Repealer filed
						5-30-80; designated effective 7-1-80 (Register 80, No.
						29).
Note: Authority cited: Sections
						  14100,
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14100,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.8 - Conditional Administrative Adjustments. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-2-76 as an emergency; effective upon filing. Certificate of
						Compliance included (Register 76, No. 23).
2. Repealer filed
						5-30-80; designated effective 7-1-80 (Register 80, No.
						29).
Note: Authority cited: Sections
						  14100,
						  14100.1,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code. Reference: Sections
						  14100,
						  14105
						  and
						  14106,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51508.9 - Medi-Cal Hospital Payment Rate Exception. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 5-20-77; effective thirtieth day thereafter (Register 77, No.
						21).
2. Repealer filed 5-30-80; designated effective 7-1-80
						(Register 80, No. 29).
Note: Authority cited: Sections
						  14100.1,
						  14105,
						  14106
						  and
						  14161,
						  Welfare and Institutions Code. Reference: Sections
						  14105,
						  14106
						  and
						  14161,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51509 - Hospital Outpatient Departments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Billing shall not exceed a provider's
					 usual charge made to the general public. Reimbursement for hospital outpatient
					 departments shall be the provider's usual charge to the general public not to
					 exceed the maximum rates authorized by this section.
(1) Maximum reimbursement rates, as shown in
					 the following schedules, include overhead and professional components, except
					 as otherwise indicated in (g) below. When these segments are billed separately,
					 the total may not exceed the amounts listed.
(2) Notwithstanding any other provisions of
					 this section, the Director may negotiate with individual hospital facilities an
					 all-inclusive per visit rate for hospital outpatient services, provided that
					 such negotiated rates do not increase overall program
					 costs.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51509.1 - Organized Outpatient Clinics

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement for organized outpatient
					 clinic services shall be the usual charges made to the general public not to
					 exceed the maximum reimbursement rates listed in this section.
(b) Organized outpatient clinics with
					 surgical facilities, as defined in Health and Safety Code Section
					 1204(b),
					 shall be reimbursed as follows.
(1) Payment
					 for surgical procedures may be made either directly to the clinic or separately
					 to the clinic, physician or dentist for the services provided by each provider.
(A) Reimbursement for clinic services shall
					 not exceed the amounts listed in (3).
(B) Reimbursement for physician or dental
					 services, normally provided in an office setting as determined by the
					 Department, shall not exceed 80 percent of the maximum allowed under Section
					 51509.1(e), or
					 Section 51506, as appropriate.
(C) Reimbursement for physician or dental
					 services, not normally provided in an office setting as determined by the
					 Department, shall not exceed the full amount allowed under Section
					 51509.1(e), or
					 Section 51506, as
					 appropriate.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51509.2 - Chronic Hemodialysis Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Renal dialysis centers and community
					 hemodialysis units shall be reimbursed the lesser of customary charges or
					 reasonable costs for services provided in accordance with Section
					 51330.
(b) The Department shall use the "Health
					 Insurance Regulations Manual" (HIRM-1), Intermediary Letters and other payment
					 guidelines issued through March 31, 1976 by the U.S. Department of Health,
					 Education, and Welfare for the administration of Title XVIII of the Social
					 Security Act:
(1) In ascertaining whether or
					 not costs are reasonable for these services.
(2) As a guide for computation of interim
					 payments and reasonable costs at final settlement.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51509.3 - Rural Health Clinic Reimbursement. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 8-1-78 as an emergency; effective upon filing (Register 78, No.
						31).
2. Editorial correction to reprint subsection (c) and history
						notes which were erroneously deleted by Register 78, No. 32 (Register 78, No.
						39).
3. Repealer filed 11-2-78 as an emergency; effective upon
						filing (Register 78, No. 44).
4. Certificate of Compliance as to
						8-1-78 emergency transmitted to OAH 11-28-78 and filed 11-29-78 (Register 78,
						No. 48).
5. Amendment of title of section filed 2-5-79; effective
						thirtieth day thereafter (Register 79, No. 6).
6. Certificate of
						Compliance as to 11-2-78 emergency filed 2-5-79 (Register 79, No.
						6).
Note: Authority cited: Sections
						  14100.1,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14100.1,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code.