reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › UTILIZATION CONTROL › Section 1126.71 - Scope of utilization review process

Current through Register Vol. 54, No. 28, July 13, 2024
Same day surgical services provided to Medical Assistance
					 recipients are subject to the utilization review procedures in Chapter 1101
					 (relating to general provisions), and in §
										1163.72 (relating to utilization
					 review: general).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › ADMINISTRATIVE SANCTIONS › Section 1126.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
If the Department determines that a provider billed for
					 services inconsistent with this chapter and Chapter 1101 (relating to general
					 provisions), provided incorrect information on the billing invoice regarding a
					 patient's diagnosis or procedures performed during the period of
					 hospitalization or otherwise violated the standards in the provider agreement,
					 the provider is subject to the sanctions in Chapter 1101.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › ADMINISTRATIVE SANCTIONS › Section 1126.82 - Administrative sanctions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the
				  ASC/SPU quality assurance/utilization review committee fails to review a
				  Medical Assistance recipient's need for admission or fails to request approval
				  for the admission through the Department's Bureau of Policy and Program
				  Development, the Department will deny payment for the stay.
(b) If the Department determines that a
				  facility billed for services inconsistent with this chapter and Chapter 1101
				  (relating to general provisions), provided incorrect information on the billing
				  invoice regarding a patient's diagnosis or procedures performed, the Department
				  will deny payment for the claims.
(c) If the Department determines that an
				  ASC/SPU claim has been inappropriately coded based on information in the
				  patient's medical record or discovers coding errors, the Department will
				  correct the claim for payment purposes.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › RIGHT OF APPEAL › Section 1126.91 - Provider right of appeal

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  hospital's right of appeal is under Chapter 1101 (relating to general
				  provisions).
(b) ASCs/SPUs and
				  practitioners do not have the right to a separate appeal on the same
				  case.
(c) For cases undergoing the
				  appeal process, payment, including adjustments, will be withheld until the case
				  is adjudicated.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › GENERAL PROVISIONS › Section 1127.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program makes payment for medical services provided
					 under the auspices of a birth center. Payment for birth center services
					 rendered to eligible recipients by birth centers enrolled as providers under
					 the program is subject to this chapter and Chapters 1101 and 1150 (relating to
					 general provisions; and MA Program payment policies) and the MA Program fee
					 schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › GENERAL PROVISIONS › Section 1127.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
All-inclusive fee
-A rate of payment that
					 covers services ordinarily furnished to a patient under the auspices of a birth
					 center.
Birth center
-A freestanding facility not
					 physically part of a hospital, which provides comprehensive obstetrical care to
					 women expected to experience a normal pregnancy, delivery and post-partum
					 period.
Obstetrical care
-edical attention and
					 supervision provided during pregnancy, labor and the post-partum period. The
					 care shall be comprehensive, covering all services included under the birth
					 center's written policies.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › SCOPE OF BENEFITS › Section 1127.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are not eligible for birth
					 center services under the MA Program unless the recipient is also categorically
					 needy or medically needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › SCOPE OF BENEFITS › Section 1127.24 - Scope of benefits for General Assistance recipients

Current through Register Vol. 54, No. 28, July 13, 2024
General Assistance recipients, age 21 to 65, whose MA
					 benefits are funded solely by State funds, are eligible for medically necessary
					 basic health care benefits as defined in Chapter 1101 (relating to general
					 provisions). See § 1101.31(e) (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › PROVIDER PARTICIPATION › Section 1127.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements established
					 in §§
										1101.41-1101.43 (relating to
					 participation) birth centers shall:
(1) Be licensed by the Department of
				  Health.
(2) Have an established fee
				  schedule for billing third party and private payors.
(3) Be licensed by the appropriate agency of
				  the state in which the birth center is located, if it is located outside this
				  Commonwealth.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › PROVIDER PARTICIPATION › Section 1127.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
Ongoing responsibilities of providers are established in
					 §
										1101.51 (relating to ongoing
					 responsibilities of providers).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › PAYMENT FOR BIRTH CENTER SERVICES › Section 1127.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment is made for services provided for participating birth centers subject
				  to the conditions and limitations established in this chapter, Chapters 1101
				  and 1150 (relating to general provisions; and MA Program payment policies) and
				  the MA Program fee schedule.
(b) A
				  total fee determined by the Department is paid to each birth center for
				  services, including professional services, provided by the facility throughout
				  the course of a routine pregnancy, delivery and post-partum period.
(c) Birth center services shall be
				  comprehensive beginning with the initial prenatal visit and concluding with the
				  final post-partum visit. The services include but are not limited to:
(1) Orientation to birth center
				  care.
(2) Twenty-four hour
				  availability of the nurse-midwife/physician team.
(3) Routine laboratory and other diagnostic
				  services. For the purpose of this chapter, routine laboratory tests include
				  only hematocrit, hemoglobin and urinalysis.
(4) Patient education regarding nutrition
				  with respect to both mother and child, substances hazardous to the health of
				  mother and child, anatomy and physiology pertaining to the mother and child
				  throughout all phases of the pregnancy, preparation for birth center delivery
				  and early discharge, infant care, parenting and options for family planning and
				  contraception.
(5) Prenatal care
				  including, but not limited to, a written social and medical history, initial
				  physical examination, examination by obstetrician, identification of risk
				  status with referral for appropriate care when indicated and visits with
				  midwife or physician.
(6) Labor,
				  delivery and newborn services including a minimum of 6 hours of post delivery
				  care.
(7) Routine medically
				  necessary medications administered in the birth center.
(8) Post-partum care that includes a minimum
				  of three visits during which the mother and baby are examined by the midwife or
				  a registered nurse. The first visit shall take place within 24 to 72 hours
				  after delivery, with subsequent visits within 6 weeks after delivery.
(9) Mileage for midwife/physician trips to
				  and from the patient's home for the purpose of visits.
(10) Facilities available to
				  patients.
(11) The maintenance of
				  medical records as required by the Department of Health and under §
											1101.51 (relating to ongoing
				  responsibilities of providers.)
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › PAYMENT FOR BIRTH CENTER SERVICES › Section 1127.52 - Payment criteria

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will establish maximum reimbursement fees for birth centers based on
				  the following criteria:
(1) The level of
				  reimbursement will be consistent with efficiency, economy and quality of
				  care.
(2) The level of
				  reimbursement will be sufficient to assure availability of services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › PAYMENT FOR BIRTH CENTER SERVICES › Section 1127.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department does not pay for services provided by a birth center except as
				  specified under §
										1127.51 (relating to general
				  payment policy).
(b) No additional
				  payment will be made for services provided by staff of a birth center for
				  services provided under the auspices of the facility.
(c) The total amount of the payments made on
				  a trimester basis will not exceed the total fee for which the facility is
				  eligible.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › PAYMENT FOR BIRTH CENTER SERVICES › Section 1127.54 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
The Department does not make payment to other providers for
					 services expected to be provided by the birth center under §
										1127.51(c) 
					 (relating to general payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › UTILIZATION CONTROL › Section 1127.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
					 subject to the utilization review procedures established in §
										1101.71 (relating to utilization
					 control).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1127 - BIRTH CENTER SERVICES › ADMINISTRATIVE SANCTIONS › Section 1127.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with this part, to have provided services outside the scope of
					 customary standards of medical practice or to have otherwise violated the
					 standards set forth in the provider agreement, are subject to the sanctions
					 described in §§
										1101.82-1101.84 (relating to
					 administrative procedures).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › GENERAL PROVISIONS › Section 1128.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program pays for renal dialysis services provided to
					 eligible MA recipients. Payment is made to participating, independently
					 operated dialysis facilities and to hospital based dialysis facilities under
					 this chapter and Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › GENERAL PROVISIONS › Section 1128.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
Home dialysis
-Dialysis performed by an
					 appropriately trained patient or patient partner at home.
MA
-Medical Assistance.
Outpatient dialysis
-Dialysis furnished on
					 an outpatient basis under the auspices of a renal dialysis facility.
Patient partner
-An individual trained to
					 assist a patient in performing self-dialysis or home dialysis.
Renal dialysis
-A process by which
					 dissolved substances are removed from a patient's body by diffusion from one
					 fluid compartment to another across a semipermeable membrane.
Renal dialysis facility
-A facility
					 approved by the Department of Health to furnish dialysis services on an
					 outpatient basis. A dialysis facility may be hospital based or may be operated
					 independently of a hospital.
Self-renal dialysis
-Dialysis performed at
					 a facility with little or no professional assistance, by a dialysis patient or
					 patient partner, who has completed an appropriate course of training.
Self-renal dialysis training
and
home renal dialysis training
-A program that trains dialysis
					 patients to perform self-dialysis or home dialysis with little or no
					 professional assistance, and trains other individuals to assist patients in
					 performing self-dialysis or home dialysis.
Staff-assisted dialysis
-Dialysis performed
					 by the staff of the center.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › SCOPE OF BENEFITS › Section 1128.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients registered with the
					 Department of Health Chronic Renal Disease Program are eligible for renal
					 dialysis services subject to this chapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › SCOPE OF BENEFITS › Section 1128.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients registered with the Department
					 of Health Chronic Renal Disease Program are eligible for renal dialysis
					 services subject to this chapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › SCOPE OF BENEFITS › Section 1128.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are not eligible for renal
					 dialysis services under the MA Program unless the recipient is also
					 categorically needy or medically needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › SCOPE OF BENEFITS › Section 1128.24 - Scope of benefits for General Assistance recipients

Current through Register Vol. 54, No. 28, July 13, 2024
General Assistance recipients, age 21 to 65, whose MA
					 benefits are funded solely by State funds, are eligible for medically necessary
					 basic health care benefits as defined in Chapter 1101 (relating to general
					 provisions). See § 1101.31(e) (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › PROVIDER PARTICIPATION › Section 1128.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
				  addition to the participation requirements established in §§
										1101.41-1101.43 (relating to
				  participation), a renal dialysis facility shall:
(1) Have a signed contractual agreement with
				  the Department of Health Chronic Renal Disease Program.
(2) Be enrolled in the MA Program as a renal
				  dialysis provider.
(3) Be Medicare
				  certified in accordance with Medicare regulations at
				  42 CFR
				  405.2100-405.2171 (relating to
				  conditions for coverage of suppliers of End-Stage Renal Disease (ESRD)
				  services).
(4) Abide by applicable
				  Federal and State statutes and regulations, including, but not limited to,
				  Title XIX of the Social Security Act (42 U.S.C.A. §§
												1396-1396s), the Public Welfare Code
				  (62
				  P. S. §§
												101-1411) and applicable
				  licensing statutes.
(5) Have an
				  established schedule of charges for billing third parties and private payors
				  that is published and made available to the general public.
(6) If requested, furnish information to the
				  Department necessary to establish rates as specified in §
											1128.53 (relating to limitations
				  on payment), in the form and manner the Department
				  requires.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › PROVIDER PARTICIPATION › Section 1128.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
Ongoing responsibilities of providers are established in
					 §
										1101.51 (relating to ongoing
					 responsibilities of providers).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › PAYMENT FOR RENAL DIALYSIS SERVICES › Section 1128.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment is made as set forth in this section, for support services and items
				  related to procedures provided by participating dialysis facilities if full
				  payment for the services and items is not available through Medicare, other
				  financial resources or health insurance programs. Payment is subject to the
				  conditions and limitations established in this chapter, Chapters 1101 and 1150
				  (relating to general provisions; and MA Program payment policies) and the MA
				  Program Fee Schedule.
(b) A fee
				  determined by the Department is paid for support services provided to an
				  eligible recipient during the course of a dialysis procedure.
(c) The dialysis facility is considered the
				  provider regardless of whether the facility is operated directly by the
				  enrolled provider or through contract between the provider and other
				  organizations or individuals. The enrolled provider is responsible for the
				  delivery of service and for billings.
(d) The Department will pay for the
				  unsatisfied portion of the Medicare deductible and remaining 20% coinsurance up
				  to the amount of the MA fee, if the Medicare 80% payment and the amount billed
				  to MA does not exceed the maximum MA fee.
(e) Payment is made for dialysis services
				  provided at the site of a facility or in a patient's home.
(f) The fee paid to the facility includes,
				  but is not limited to, the following:
(1)
				  Nursing, technician and related services.
(2) Use of the facility.
(3) The maintenance of medical records as
				  required by the Department of Health and under §
											1101.51 (relating to ongoing
				  responsibilities of providers.)
(4)
				  Drugs, biologicals, surgical dressings, supplies, blood, intravenous fluids,
				  diagnostic studies and equipment directly related to the provision of a
				  dialysis procedure.
(5) Ongoing
				  evaluation of patients receiving home dialysis services.
(6) Dietary, social services and other
				  related services.
(7)
				  Administrative and housekeeping items and services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › PAYMENT FOR RENAL DIALYSIS SERVICES › Section 1128.52 - Payment criteria

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will establish maximum reimbursement fees for dialysis facilities
				  based on the following criteria:
(1) The level
				  of reimbursement will be consistent with efficiency, economy and quality of
				  care.
(2) The level of
				  reimbursement will be sufficient to assure availability of services.
(3) Rate increases and decreases, and changes
				  in the actual methodology used in establishing the maximum fees will be
				  published as a notice in the
Pennsylvania Bulletin
.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › PAYMENT FOR RENAL DIALYSIS SERVICES › Section 1128.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department does not pay for services provided by a dialysis facility except as
				  specified under §
										1128.51 (relating to general
				  payment policy).
(b) Payment will
				  not be made for services provided by facility based or contract employes if the
				  services are those specified under § 1128.51.
(c) Payment is limited to services provided
				  to recipients who meet Federal Medicaid eligibility requirements and who are
				  enrolled in the Department of Health Chronic Renal Disease Program.
(d) Payment is limited to one procedure
				  including related services, per day.
(e) Initial training for home dialysis is
				  limited to 24 sessions per patient or partner.
(f) Payment for backup visits to the facility
				  is limited to no more than 15 in one calendar year. For the purposes of this
				  chapter, backup procedures are dialysis procedures provided at a facility when
				  a patient is required to resume treatment at the facility following home
				  dialysis treatment. Backup services may be necessitated by worsening of the
				  patient's condition, absence of the dialysis treatment partner, or for the
				  purpose of training a new partner or retraining for a new procedure to be
				  managed in the home.
(g) Payment
				  for nonexpendable equipment or installation of equipment necessary for home
				  dialysis procedures is limited to one time per patient per item.
This section cited in 55 Pa. Code §
												1128.41 (relating to participation
						requirements).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › PAYMENT FOR RENAL DIALYSIS SERVICES › Section 1128.54 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
The Department does not pay dialysis facilities for:
(1) Services that do not conform to
				  this chapter.
(2) Services provided
				  by a dialysis facility that does not meet the Federal Medicare requirements at
				  42 CFR
				  405.2100 (relating to scope of
				  subpart).
(3) Services and items to
				  the extent that payment is available through Medicare, other health insurance
				  programs or financial resources.
(4) Diagnostic or therapeutic procedures
				  solely for experimental, research or educational purposes.
(5) Procedures that are not listed in the MA
				  Program fee schedule.
(6) Services
				  that are not medically necessary.
(7) Services provided to recipients who are
				  hospital inpatients.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › UTILIZATION CONTROL › Section 1128.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
					 subject to the utilization review procedures established in §
										1101.71 (relating to utilization
					 control).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1128 - RENAL DIALYSIS SERVICES › ADMINISTRATIVE SANCTIONS › Section 1128.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
A provider determined to have billed for services
					 inconsistent with MA Program regulations, to have provided services outside the
					 scope of customary standards of medical practice or to have otherwise violated
					 the standards in the provider agreement, is subject to the sanctions described
					 in Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › GENERAL PROVISIONS › Section 1129.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for medical services
					 provided under the auspices of a rural health clinic. Payment for rural health
					 clinic services rendered to eligible recipients by rural health clinics
					 enrolled as providers under the program is subject to this chapter and Chapters
					 1101 and 1150 (relating to general provisions; and MA Program payment policies)
					 and the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › SCOPE OF BENEFITS › Section 1129.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for rural
					 health clinic services as defined at
					 42 CFR
					 440.20(b).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › SCOPE OF BENEFITS › Section 1129.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for rural health
					 clinic services as defined at
					 42 CFR
					 440.20(b).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › SCOPE OF BENEFITS › Section 1129.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are eligible for rural
					 health clinic services as defined at
					 42 CFR
					 440.20(b).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › SCOPE OF BENEFITS › Section 1129.24 - Scope of benefits for General Assistance recipients

Current through Register Vol. 54, No. 28, July 13, 2024
General Assistance recipients, age 21 to 65, whose MA
					 benefits are funded solely by State funds, are eligible for medically necessary
					 basic health care benefits as defined in Chapter 1101 (relating to general
					 provisions). See § 1101.31(e) (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › PROVIDER PARTICIPATION › Section 1129.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
				  addition to the participation requirements established in Chapter 1101
				  (relating to general provisions), rural health clinics shall:
(1) Participate in the Medicare
				  Program.
(2) Sign a provider
				  agreement with the Department.
(3)
				  Have an established fee schedule for billing third party and private
				  payors.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › PAYMENT FOR RURAL HEALTH CLINIC SERVICES › Section 1129.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment will be made for rural health clinic services rendered at the clinic,
				  at a hospital or at the place of residence of the patient.
(b) Payment for rural health clinic services
				  will be made on the basis of an all-inclusive visit fee established by the
				  Medicare carrier. When the cost for a service provided by the clinic is
				  included in the established visit fee, the practitioner rendering the service
				  shall not bill the MA Program for it separately.
(c) An adjustment to the all-inclusive visit
				  fee will be made when the Medicare carrier determines the difference, if any,
				  between the total payment due the clinic and the total payment made during the
				  reported period. The adjustment will be made as follows:
(1) If the clinic has been underpaid, the
				  Department will make a lump sum payment for the amount due.
(2) If the clinic has been overpaid, the
				  clinic shall make a lump sum payment to the Department for the amount due. A
				  repayment plan not to exceed 1 year will be arranged by the Department at the
				  request of the clinic if the Department is satisfied that a lump sum payment
				  would impose severe financial hardship on the clinic.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › PAYMENT FOR RURAL HEALTH CLINIC SERVICES › Section 1129.52 - Payment policy for provider rural health clinics

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will be made for rural health clinic services and
					 other covered services provided by a provider rural health clinic on an
					 all-inclusive fee basis as established by the Medicare carrier.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › PAYMENT FOR RURAL HEALTH CLINIC SERVICES › Section 1129.53 - Payment policy for independent rural health clinics

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment will be made for rural health
				  clinic services as defined in §
										1129.2 (relating to definitions)
				  provided by an independent rural health clinic on an all-inclusive visit fee
				  basis as established by the Medicare carrier for rural health
				  clinics.
(b) Covered service
				  provided outside the scope of rural health clinic services as defined in §
										1129.2 will only be paid by the
				  Department according to the chapter governing payment for the specific service
				  as set forth in this title.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › PAYMENT FOR RURAL HEALTH CLINIC SERVICES › Section 1129.54 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for rural health clinic services is subject to the
					 Medicare payment conditions set forth at
					 42 CFR
					 405.2401-405.2430.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › PAYMENT FOR RURAL HEALTH CLINIC SERVICES › Section 1129.55 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
Rural health clinic services are subject to the payment
					 limitations set forth at 42
					 CFR 405.2401-405.2430.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › PAYMENT FOR RURAL HEALTH CLINIC SERVICES › Section 1129.56 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
A service not included in the all-inclusive visit fee as
					 set by the Medicare carrier in accordance with
					 42 CFR
					 405.2401-405.2430 is
					 noncompensable as a rural health service but may be compensable under other MA
					 regulations.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › UTILIZATION CONTROL › Section 1129.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
					 subject to the utilization review procedures established in Chapter 1101
					 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1129 - RURAL HEALTH CLINIC SERVICES › ADMINISTRATIVE SANCTIONS › Section 1129.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with MA Program regulations, to have provided services outside the
					 scope of customary standards of medical practice, or to have otherwise violated
					 the standards set forth in the provider agreement, are subject to the sanctions
					 described in Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › GENERAL PROVISIONS › Section 1130.1 - Statutory basis

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter implements section 1905(o) of the Social
					 Security Act (42 U.S.C.A.
					 §
											1396d(o)). Section
					 1905(a)(18) lists hospice care as a MA service. Section 1905(o) defines hospice
					 care.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › GENERAL PROVISIONS › Section 1130.2 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program covers hospice care furnished to eligible MA
					 recipients by hospices enrolled in the Program. Payment for hospice care is
					 subject to this chapter, Chapters 1101 and 1150 (relating to general
					 provisions; and MA Program payment policies) and the procedures listed in the
					 MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › GENERAL PROVISIONS › Section 1130.3 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
Attending physician
-A physician who
					 is:
(i) A doctor of medicine or
				  osteopathy.
(ii) Identified by the
				  recipient, at the time he elects to receive hospice care, as having the most
				  significant role, in the determination and delivery of medical care to the
				  recipient.
Bereavement counseling
-Guidance and
					 spiritual support provided to the recipient's family after the recipient's
					 death.
Certification period
-A period of 60
					 consecutive days, at the beginning of which a certification of terminal illness
					 has been filed under §
										1130.22 (relating to duration of
					 coverage).
Core services
-Nursing care, medical social
					 services, physician services and counseling services as specified in Medicare
					 regulations at 42 CFR
					 418.82 -
					 418.88 (relating to core
					 services).
Employe of the hospice
-An individual
					 performing a substantial and regular service for the hospice either for
					 remuneration by the hospice provider or on a voluntary basis. The term includes
					 an individual who provides some services on a voluntary basis and receives
					 payment for other services and an individual who is appropriately trained and
					 assigned to the hospice unit if the hospice is a subdivision of an agency or
					 organization.
Freestanding hospice
-A hospice that is not
					 part of another type of participating provider.
Hospice
-A public agency or private
					 organization or subdivision of either of these that is primarily engaged in
					 providing care to terminally ill individuals.
Hospice services
-Services that are
					 reasonable and necessary for the palliation or management of the recipient's
					 terminal illness and related conditions.
Representative
-A person who, because of
					 the recipient's mental or physical incapacity, is authorized in accordance with
					 State law to execute or revoke an election for hospice care or terminate
					 curative medical care on behalf of the terminally ill recipient.
Terminally ill
-A recipient who has a
					 medical prognosis that his life expectancy is 6 months or less.
Unrelated condition
-A health problem that
					 could not reasonably be expected to be caused by the terminal illness. The term
					 includes a dental abscess in a recipient with terminal cancer of the colon and
					 a nonpathologic fracture or other injury sustained by a recipient with lung
					 cancer; a pre-existing condition such as diabetes would also be considered
					 unrelated to a terminal diagnosis such as leukemia.
This section cited in 55 Pa. Code §
												1130.41 (relating to election of
						hospice care); and 55 Pa. Code §
												1130.51 (relating to provider
						enrollment requirements).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › RECIPIENT ELIGIBILITY AND DURATION OF COVERAGE › Section 1130.21 - Recipient eligibility requirements

Current through Register Vol. 54, No. 28, July 13, 2024
To be eligible to elect hospice care under the MA Program,
					 an individual shall:
(1) Be
				  categorically or medically needy.
(2) Be residing at home, which includes the
				  recipient's home, a friend's home, a relative's home, a hotel, a boarding
				  house, a personal care home, a domiciliary care facility, an intermediate care
				  facility or a skilled nursing facility. The individual may not be residing in a
				  hospital.
(3) Be certified as being
				  terminally ill by a doctor of medicine or osteopathy under §
										1130.22 (relating to duration of
				  coverage).
(4) Agree to waive
				  rights to MA Program coverage for the following services for the period during
				  which the recipient is under the care of a designated hospice:
(i) Hospice care provided by a hospice other
				  than the hospice designated by the recipient, unless provided under
				  arrangements made by the designated hospice.
(ii) MA services related to the treatment of
				  the terminal condition for which hospice care was elected or a related
				  condition or services that are equivalent to hospice care except for:
(A) Services provided by the designated
				  hospice.
(B) Services provided by
				  another hospice under arrangements made by the designated hospice.
(C) Services provided by the recipient's
				  attending physician if that physician is not an employe of the designated
				  hospice or receiving compensation from the hospice for those
				  services.
(D) Medications
				  prescribed for conditions clearly unrelated to the terminal illness.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › RECIPIENT ELIGIBILITY AND DURATION OF COVERAGE › Section 1130.22 - Duration of coverage

Current through Register Vol. 54, No. 28, July 13, 2024
There is no limit on the available number of days of
					 hospice coverage for a recipient who meets the eligibility requirements of
					 §
										1130.21 (relating to recipient
					 eligibility requirements) and who is certified as being terminally ill in
					 accordance with the following procedures:
(1)
Basic requirement.
For
				  the first 60-day period of hospice coverage, the hospice obtains, within 2
				  calendar days after hospice care is initiated, a completed certification of
				  terminal illness form signed by:
(i) The
				  medical director of the hospice or the physician member of the hospice
				  interdisciplinary group.
(ii) The
				  recipient's attending physician if the recipient has an attending
				  physician.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › RECIPIENT ELIGIBILITY AND DURATION OF COVERAGE › Section 1130.23 - Scope of benefits for General Assistance recipients

Current through Register Vol. 54, No. 28, July 13, 2024
General Assistance recipients, age 21 to 65, whose MA
					 benefits are funded solely by State funds, are eligible for medically necessary
					 basic health care benefits as defined in Chapter 1101 (relating to general
					 provisions). See § 1101.31(e) (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › ELECTION AND REVOCATION OF HOSPICE CARE › Section 1130.41 - Election of hospice care

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Election statement.
If a recipient who meets the eligibility
				  requirements for hospice care elects to receive that care, the recipient or the
				  recipient's representative shall file, with a particular hospice, the election
				  statement specified in Appendix B.
(b)
Effective date of
				  election
. An election date may not be a date that is earlier than the
				  date the election is made.
(c)
Change of designated hospice
. The recipient or the recipient's
				  representative may change the designation of the hospice from which the
				  recipient wishes to receive care once in each certification period as defined
				  in §
										1130.3 (relating to definitions).
				  To change hospices, the recipient or the recipient's representative shall file
				  with the hospice from which care has been received and with the newly
				  designated hospice, the change of hospice statement specified in Appendix
				  C.
This section cited in 55 Pa. Code §
												1130.61 (relating to prerequisites
						for coverage).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › ELECTION AND REVOCATION OF HOSPICE CARE › Section 1130.42 - Revocation of hospice care

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Right to revoke
. The recipient or the recipient's
				  representative may revoke the recipient's election of hospice care at any time.
				  To revoke the election of hospice care, the recipient, or the recipient's
				  representative shall file with the hospice the revocation statement specified
				  in Appendix D.
(b)
Effect
				  of revocation
. A recipient who revokes the election of hospice care:
(1) Is no longer covered under the MA Program
				  for hospice care.
(2) Resume full
				  MA Program coverage as applicable to the recipient's category of assistance at
				  the time of revocation, including those services waived under §
											1130.21(a)(4)
				  (relating to recipient eligibility requirements).
(3) May elect, at any time, to resume hospice
				  coverage under §
											1130.22 (relating to duration of
				  coverage).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › CONDITIONS OF PARTICIPATION › Section 1130.51 - Provider enrollment requirements

Current through Register Vol. 54, No. 28, July 13, 2024
To qualify for enrollment as a provider of hospice services
					 under the MA Program, a hospice shall:
(1) Meet the definition of a hospice in
				  §
										1130.3 (relating to
				  definitions).
(2) Be Medicare
				  certified.
(3) Comply with the
				  prerequisites for participation established in §§
										1101.11,
				  1101.42 and
				  1101.43(b)(1) and
				  (5) (relating to general provisions;
				  prerequisites for participation; and enrollment and ownership reporting
				  requirements).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › CONDITIONS OF PARTICIPATION › Section 1130.52 - Ongoing responsibilities of hospice providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) To retain the right to participate in the
				  MA Program, a provider of hospice services shall:
(1) Be Medicare certified and continue to
				  meet the Medicare conditions for participation as a hospice as set forth at 42
				  CFR Part 418 , Subpart C (relating to conditions of participation).
(2) Fulfill the applicable requirements of
				  §§
											1101.42,
				  1101.43(b)(1) and
				  (5) and
				  1101.51 (relating to prerequisites
				  for participation; enrollment and ownership reporting requirements; and ongoing
				  responsibilities of providers).
(3)
				  Fully inform each recipient or representative, in writing prior to admission to
				  the hospice, regarding the following:
(i)
				  Conditions the hospice imposes.
(ii) What services the hospice
				  provides.
(iii) The names of other
				  facilities such as hospitals and nursing facilities with which the hospice has
				  agreements for general inpatient or respite care.
(iv) The recipient's rights under the MA
				  Program with respect to changing the designated hospice, revoking hospice care
				  and receiving care from a physician of the patient's choice.
(v) The fact that the recipient may be
				  notified by the CAO that he is required to pay a specific amount towards
				  hospice care, with respect to a recipient residing in a nursing
				  facility.
(4) Ensure that
				  enrollment of MA recipients in a hospice is without regard to age, race, creed,
				  sex, physical or mental handicap, national origin, marital status or sexual
				  preference.
(5) Not contract or
				  otherwise arrange for hospice service to be provided either directly or
				  indirectly to a MA recipient by a provider who has been suspended or terminated
				  from participation in the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › COVERED SERVICES › Section 1130.61 - Prerequisites for coverage

Current through Register Vol. 54, No. 28, July 13, 2024
To be covered, hospice services shall meet the following
					 requirements:
(1) The services shall
				  be reasonable and necessary for the palliation or management of the symptoms of
				  the terminal illness as well as related conditions.
(2) The recipient shall have elected hospice
				  care under §
										1130.41 (relating to election of
				  hospice care).
(3) A plan of care
				  shall be established in accordance with Medicare regulations at
				  42 CFR
				  418.58 (relating to condition of
				  participation-plan of care) before the services are provided.
(4) The services shall be consistent with the
				  plan of care.
(5) A certification
				  that the individual is terminally ill shall be completed under §
										1130.22 (relating to duration of
				  coverage).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › COVERED SERVICES › Section 1130.62 - Covered services

Current through Register Vol. 54, No. 28, July 13, 2024
The following services are covered hospice services when
					 provided in accordance with the Medicare regulations at
					 42 CFR
					 418.202 (relating to covered
					 services):
(1) Nursing care.
(2) Medical social services.
(3) Physicians' services.
(4) Counseling services.
(5) Short-term inpatient care.
(6) Medical supplies and
				  appliances.
(7) Drugs that are used
				  primarily for the relief of pain and symptom control related to the terminal
				  illness.
(8) Home health aide
				  services.
(9) Physical therapy,
				  occupational therapy and speech-language pathology services.