reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.68 - Invoicing for services

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Invoices.
When billing for MA services or items, a provider
				  shall use the invoices specified by the Department or its agents, according to
				  billing and other instructions contained in the provider handbooks.
(b)
Time frame.
MA providers
				  shall submit invoices correctly and in accordance with established time frames.
				  For purposes of this section, time frames referred to are indicated in calendar
				  days.
(1) A provider shall submit original or
				  initial invoices to be received by the Department within a maximum of 180 days
				  after the date the services were rendered or compensable items provided.
				  Nursing facility providers and ICF/MR providers shall submit original or
				  initial claims to be received by the Department within 180 days of the last day
				  of a billing period. A billing period for nursing facility providers and ICF/MR
				  providers covers the services provided to an eligible recipient during a
				  calendar month and starts on the first day service is provided in that calendar
				  month and ends on the last day service is provided in that calendar
				  month.
(2) Departmental receipt of
				  a claim is evidenced by appearance of the claim on a remittance advice (RA).
				  The claim reference number (CRN) identifies when the claim was received by the
				  Department. The first digit of the CRN indicates the year. The next three
				  digits refer to the Julian Calendar date.
(3) Resubmission of a rejected original claim
				  or a claim adjustment shall be received by the Department within 365 days of
				  the date of service, except for nursing facility providers and ICF/MR
				  providers. Resubmission of a rejected original claim or claim adjustment by a
				  nursing facility provider or an ICF/MR provider shall be received by the
				  Department within 365 days of the last day of each billing period.
(4) A claim which has been submitted to the
				  Department not appearing within 45 days following that submission, should be
				  resubmitted by the provider. Similarly, a claim which appears as a pend on a
				  remittance advice and does not subsequently appear as an approved or rejected
				  claim before the expiration of an additional45 days should be resubmitted
				  immediately by the provider.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.71 - Utilization control

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department, in accordance with section 1902(a)(30) of the Social Security Act
				  (42 U.S.C.A. §
											1396(a)(30)), has
				  established procedures for reviewing the utilization of, and payment for,
				  Medical Assistance services. Providers are required, upon request, to furnish
				  the Department or its designated agents, the Office of the Attorney General or
				  the Secretary of Health and Human Services, with medical and fiscal records as
				  specified in §
										1101.51(e)
				  (relating to ongoing responsibilities of providers). Providers shall cooperate
				  with audits and reviews made by the Department for the purpose of determining
				  the validity of claims and the reasonableness and necessity of service provided
				  or for any other purpose.
(b)
				  Providers shall submit to the Department or the Secretary of Health and Human
				  Services or to the Office of the Attorney General of this Commonwealth within
				  35 days of request, information related to business transactions which shall
				  include complete information about:
(1) The
				  ownership of any subcontractor with whom the provider has had business
				  transactions totaling more than $25,000 during the 12-month period ending on
				  the date of the request; and
(2)
				  Any significant business transactions between the provider and any wholly owned
				  supplier, or between the provider and any subcontractor, during the 5-year
				  period ending on the date of the request.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.72 - Invoice adjustment

Current through Register Vol. 54, No. 28, July 13, 2024
The Bureau of Utilization Review on a prepayment review may
					 either reject invoices or adjust invoices downward to eliminate noncompensable
					 items or items that are not medically necessary. Also, future invoices may be
					 adjusted downward to correct previous overpayments discovered through
					 postpayment invoice review.
This section cited in 55 Pa. Code §
												5221.43 (relating to quality
						assurance and utilization review).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.73 - Provider misutilization and abuse

Current through Register Vol. 54, No. 28, July 13, 2024
If the Department's routine utilization review procedures
					 indicate that a provider has been billing for services that are inconsistent
					 with MA regulations, unnecessary, inappropriate to patients' health needs or
					 contrary to customary standards of practice, the provider will be notified in
					 writing that payment on all of his invoices will be delayed or suspended for a
					 period not to exceed 120 days pending a review of his billing and service
					 patterns. Some providers may have their invoices reviewed prior to payment. In
					 addition, the provider's medical or fiscal records, or both, may be reviewed
					 and he may be asked to appear before one of the Department's peer review
					 committees to explain his billing practices. Written notice of the Department's
					 action to delay payment will also be sent to the PSRO, where
					 applicable.
This section cited in 55 Pa. Code Chapter 1181 Appendix O
						(relating to OBRA sanctions); and 55 Pa. Code §
												5221.43 (relating to quality
						assurance and utilization review).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.74 - Provider fraud

Current through Register Vol. 54, No. 28, July 13, 2024
If, after investigation, the Department determines that a
					 provider has submitted or has caused to be submitted claims for payments which
					 the provider is not otherwise entitled to receive, the Department will, in
					 addition to the administrative action described in §§
										1101.82-1101.84 (relating to
					 administrative procedures), refer the case record to the Medicaid Fraud Control
					 Unit of the Department of Justice for further investigation and possible
					 referral for prosecution under Federal, State and local laws. Providers who are
					 convicted by a Federal court of willfully defrauding the Medicaid program are
					 subject to a $25,000 fine or up to five years imprisonment or
					 both.
This section cited in 55 Pa. Code §
												51.27 (relating to misuse and
						abuse of funds and damage of participants property); 55 Pa. Code §
												5221.43 (relating to quality
						assurance and utilization review); and 55 Pa. Code §
												6100.744 (relating to additional
						conditions and sanctions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.75a - Business arrangements between nursing facilities and pharmacy providers-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
General.
The following listings, which are not all-inclusive,
				  set forth examples of items and practices that would be considered accepted or
				  improper under the Program.
(b)
Accepted practices.
Ancillary enhancements that are solely
				  confined to the practice of pharmacy as defined in section 2(11) of the
				  Pharmacy Act (63 P. S. §
											390-2(11)) and remain in the
				  control and ownership of the pharmacy would be considered an accepted practice
				  under section 1407(a)(2) of the Public Welfare Code (62 P. S. §
											1407(a)(2)) and §
										1101.75(a)(3)
				  (relating to provider prohibited acts).
(c)
Examples of accepted
				  practices.
Examples of accepted practices include:
(1) Medication carts whether the pharmacy
				  uses unit dose or standard prescription containers.
(2) Treatment and medication forms that are
				  already part of the pharmacy's software and may be supplied to the nursing
				  facility. The nursing facility shall pay for the cost of paper.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.76 - Criminal penalties

Current through Register Vol. 54, No. 28, July 13, 2024
A person who is convicted of committing an offense listed
					 in §
										1101.75(a)(1)-(10) and
					 (12)-(14) (relating to provider prohibited
					 acts) will be subject to the following penalties:
(1) For the first conviction, the person is
				  guilty of a felony of the third degree and is subject to a maximum penalty of a
				  $15,000 fine and 7 years imprisonment for each violation.
(2) When a person has been previously
				  convicted in a State or Federal court of conduct that would constitute a
				  violation of §
										1101.75(a)(1)-(10) and
				  (12)-(14), a subsequent allegation,
				  indictment or information under §
										1101.75(a) shall
				  be classified as a felony of the second degree with a maximum penalty of
				  $25,000 and 10 years imprisonment.
(3) In addition to the penalties specified in
				  subsections (a) and (b) and as ordered by the court, the convicted person shall
				  repay the amount of excess benefits or payments received under the program,
				  plus interest on the amount at the maximum legal rate. Interest will be
				  calculated from the date payment was made by the Department to the date full
				  repayment is made to the Commonwealth.
(4) As ordered by the Court, a convicted
				  person shall pay to the Commonwealth an amount not to exceed threefold the
				  amount of excess benefits or payments.
(5) The convicted person is ineligible to
				  participate in the program for 5 years from the date of the
				  conviction.
The provisions of this §
												1101.76 issued sections 403(a) and
						(b), 441.1 and 1410 under the act of June 13, 1967 (P. L. 31, No. 21)
						(62
						P. S. §§
													403(a) and
						(b),
						441.1 and
						1410).
This section cited in 55 Pa. Code §
												1101.75 (relating to provider
						prohibited acts).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.77 - Enforcement actions by the Department

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Departmental determination of
				  violation.
The Department may terminate a provider's enrollment and
				  direct and indirect participation in the MA Program and seek restitution as
				  specified in §
										1101.83 (relating to restitution
				  and repayment) if it determines that a provider, an employe of the provider or
				  an agent of the provider has:
(1) Failed to
				  comply with this chapter or the appropriate separate chapters relating to each
				  provider type.
(2) Committed a
				  prohibited act as specified in this chapter or the appropriate separate chapter
				  relating to each provider type or under Article XIV of the Public Welfare Code
				  (62
				  P. S. §§
												1401-1411).
(3) Failed to comply with the conditions of
				  participation listed in Articles IV or XIV of the Public Welfare Code
				  (62
				  P. S. §§
												401-493 and
				  1401-1411).
(4) Not complied with the terms of the
				  provider agreement.
(5) Been
				  suspended or terminated from Medicare.
(6) Been convicted of a Medicare or Medicaid
				  related criminal offense as certified by a Federal, State or local
				  court.
(7) Been convicted of a
				  criminal offense under State or Federal laws relating to the practice of the
				  provider's profession as certified by a court.
(8) Been subject to a disciplinary action
				  taken or entered against the provider in the records of the State licensing or
				  certifying agency.
(9) Had a
				  controlled drug license withdrawn or failed to report to the Department changes
				  in the Provider's Drug Enforcement Agency Number.
(10) Rendered or ordered services or items
				  which the Department's medical professionals have determined to be harmful to
				  the recipient, of inferior quality or medically unnecessary.
(11) Ordered services for recipients or
				  billed the Department for rendering services to recipients at an unregistered
				  shared health facility after the shared health facility and provider are
				  notified by the Department that the shared health facility is not
				  registered.
(12) Refused to permit
				  duly authorized State or Federal officials or their agents to examine the
				  provider's medical, fiscal or other records as necessary to verify services or
				  claims for payment under the program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.77a - Termination for convenience and best interests of the Department-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Effective
				  December 19, 1996, under §
										1101.77(b)(1)
				  (relating to enforcement actions by the Department), the Department will
				  terminate the enrollment and direct and indirect participation of, and suspend
				  payments to, an ICF/MR, inpatient psychiatric hospital or rehabilitation
				  hospital provider that expands its existing licensed bed capacity by more than
				  ten beds or 10%, whichever is less, over a 2-year period, unless the provider
				  obtained a Certificate of Need or letter of nonreviewability from the
				  Department of Health dated on or prior to December 18, 1996, approving the
				  expansion. Effective August 11, 1997, under §
										1101.77(b), the
				  Department will terminate the enrollment and direct and indirect participation
				  of, and suspend payments to, a nursing facility provider that expands its
				  existing licensed bed capacity. A nursing facility provider that, prior to
				  August 11, 1997, relied on the interim policy effective December 19, 1996, and
				  substantially implemented a project to expand its facility by ten beds or 10%,
				  whichever is less, within a 2-year period, will not be terminated from
				  enrollment under this policy.
(b)
				  The Department will consider exceptions to subsection (a) on a case-by-case
				  basis. Exceptions requested by nursing facilities will be reviewed under §
										1187.21a (relating to nursing
				  facility exception requests-statement of policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › ADMINISTRATIVE PROCEDURES › Section 1101.82 - Re-enrollment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Request
				  for re-enrollment.
To request re-enrollment, the provider shall send a
				  written request to the Department's Office of Medical Assistance, Bureau of
				  Provider Relations. For the request to be considered, it should include
				  statements from peer review bodies, probation officers where appropriate, or
				  professional associates, giving factual evidence of why they believe the
				  violations leading to the termination will not be repeated. A statement from
				  the provider setting forth the reasons why he should be re-enrolled should also
				  be included.
(b)
Criteria
				  for provider re-enrollment.
In considering the provider's request for
				  re-enrollment, the Department will take into account such factors as the
				  severity of the offense, whether there has been any licensure action against
				  the provider, whether the provider has been convicted in a State, Federal or
				  local court of Medicaid offenses and whether there are any claims or penalties
				  outstanding against the provider. If the Department's notice of termination or
				  exclusion specifies a date after which the Department will consider
				  re-enrolling the provider, the Department will, under no circumstances,
				  consider re-enrolling the provider before the specified date. Departmental
				  rejection of a request for re-enrollment prior to the specified date is not
				  subject to appeal.
(c)
Notification of action on re-enrollment request.
The provider
				  will be notified in writing of the Department's decision on a request within 60
				  days of the date of receipt of the application. Under no circumstances will
				  re-enrollment be granted retroactive to the date of application.
This section cited in 55 Pa. Code §
												1101.74 (relating to provider
						fraud); 55 Pa. Code §
												1127.81 (relating to provider
						misutilization); and 55 Pa. Code Chapter 1181 Appendix O (relating to OBRA
						sanctions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › ADMINISTRATIVE PROCEDURES › Section 1101.83 - Restitution and repayment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If
				  the Department determines that a provider has billed and been paid for a
				  service or item for which payment should not have been made, it will review the
				  provider's paid and unpaid invoices and compute the amount of the overpayment
				  or improper payment. The Department will use statistical sampling methods and,
				  where appropriate, purchase invoices and other records for the purpose of
				  calculating the amount of restitution due for a service, item, product or drug
				  substitution.
(b) The Department
				  may seek reimbursement from the ordering or prescribing provider for payments
				  to another provider, if the Department determines that the ordering or
				  prescribing provider has done either of the following:
(1) Prescribed excessive diagnostic services;
				  or
(2) Ordered diagnostic services
				  or treatment or both, without documenting the medical necessity for the service
				  or treatment in the medical record of the MA recipient.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › ADMINISTRATIVE PROCEDURES › Section 1101.84 - Provider right of appeal

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Right to appeal from termination of a provider's enrollment and
				  participation.
If a provider's enrollment and participation are
				  terminated by the Department, the provider may appeal the Department's
				  decision, subject to the following conditions:
(1) If a provider's enrollment and
				  participation are terminated by the Department under the provider's termination
				  or suspension from Medicare or conviction of a criminal act under §
											1101.75 (relating to provider
				  prohibited acts), the provider may appeal the Department's action only on the
				  issue of identity.
(2) If the
				  Department has terminated a provider's enrollment and participation for an
				  additional cause unrelated to the conviction or disciplinary action as
				  specified in §
											1101.77(b)(3) 
				  (relating to enforcement actions by the Department), the provider may only
				  appeal the period of the termination attributable to that additional
				  cause.
(3) A written Notice of
				  Appeal shall be filed within 30 days of the date of the notice of termination.
				  The Notice of Appeal will be considered filed on the date it is received by the
				  Director, Office of Hearings and Appeals.
(4) The Notice of Appeal shall include a copy
				  of the letter of termination, state the actions being appealed and explain in
				  detail the reasons for the appeal.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › VIOLATIONS › Section 1101.91 - Recipient misutilization and abuse

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Identification of recipient
				  misutilization and abuse.
It is a function of the CAO to identify
				  recipient misutilization; abuse or possible fraud in relation to the MA
				  Program. Therefore, providers should notify the CAO if they have reason to
				  believe that a recipient is misutilizing or abusing MA services or may be
				  defrauding the MA Program. In addition, the Department has established
				  procedures for reviewing recipient utilization of MA services. The review
				  procedures identify recipients or families that are receiving excessive or
				  unnecessary treatment, diagnostic services, drugs, medical supplies, or other
				  services by visiting numerous practitioners. If the results of the Department's
				  review warrant it, the recipient will be placed on the restricted recipient
				  program, which means that he will be restricted to obtaining certain services
				  from a single provider of his choice.
(b)
Restricted recipient
				  program.
A recipient who has been placed on the restricted recipient
				  program will be notified in writing at least 10 days prior to the effective
				  date of the restriction. The notice will include the name of a proposed
				  provider which will become the one the recipient shall use if he does not
				  notify the Department, in writing, prior to the effective date of the
				  restriction, that he wishes to choose a different provider. If, during a period
				  of restriction, a recipient wishes to change a designated provider, a 30-day
				  written notice shall be given in writing to the Office of Medical
				  Assistance.
This section cited in 55 Pa. Code §
												1101.33 (relating to recipient
						eligibility); 55 Pa. Code §
												1121.54 (relating to
						noncompensable services and items); and 55 Pa. Code §
												1141.53 (relating to payment
						conditions for outpatient services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › VIOLATIONS › Section 1101.92 - Recipient prohibited acts, criminal penalties and civil penalties

Current through Register Vol. 54, No. 28, July 13, 2024
(a) It shall be
				  unlawful for a person to commit any of the following acts:
(1) Knowingly or intentionally make or cause
				  to be made a false statement or representation of a material fact in an
				  application for a benefit or payment.
(2) Having knowledge of the occurrence of an
				  event affecting his initial or continued right to a benefit or payment or the
				  initial or continued right to a benefit or payment of another individual in
				  whose behalf he has applied for or is receiving the benefit or payment, conceal
				  or fail to disclose the event with an intent fraudulently to secure the benefit
				  or payment either in a greater amount or quantity than is due or when no the
				  benefit or payment is authorized.
(3) Having made application to receive a
				  benefit or payment for the use and benefit of himself or another and having
				  received it, knowingly or intentionally convert the benefit or a part of it to
				  a use other than for the use and benefit of himself or the other
				  person.
(4) Knowingly or
				  intentionally visit more than three practitioners or providers, who specialize
				  in the same field, in the course of 1 month for the purpose of obtaining
				  excessive services or benefits beyond what is reasonably needed (as determined
				  by medical professionals engaged by the Department) for the treatment of a
				  diagnosed condition of the recipient.
(5) Borrow or use a MA identification card
				  for which he is not entitled or otherwise gain or attempt to gain medical
				  services covered under the MA Program if he has not been determined eligible
				  for the Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › VIOLATIONS › Section 1101.93 - Restitution by recipient

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to civil action or criminal prosecution and
					 upon written notification by the Office of Medical Assistance or the Office of
					 Claims Settlement, a recipient shall reimburse the Department for services,
					 supplies and drugs that were improperly obtained, transferred to other persons,
					 resold or exchanged for other merchandise or products.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › VIOLATIONS › Section 1101.94 - Recipient right of appeal

Current through Register Vol. 54, No. 28, July 13, 2024
Departmental actions against a recipient for misutilization
					 and abuse, which include assignment to the restricted recipient program, are
					 subject to the right of appeal in accordance with Chapter 275 (relating to
					 appeal and fair hearing and administrative disqualification hearings).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › VIOLATIONS › Section 1101.95 - Conflicts between general and specific provisions

Current through Register Vol. 54, No. 28, July 13, 2024
To the extent, if any, that this chapter conflicts with the
					 specific regulations for various services or items contained in this part, this
					 chapter will control unless the specific regulations are one of the following,
					 in which case the specific regulations control:
(1) Chapter 1245 (relating to ambulance
				  transportation).
(2) Chapter 1145
				  (relating to chiropractors' services).
(3) Chapter 1221 (relating to clinic and
				  emergency room services).
(4)
				  Chapter 1223 (relating to outpatient drug and alcohol clinic
				  services).
(5) Chapter 1241
				  (relating to early and periodic screening diagnosis and treatment
				  program).
(6) Chapter 1225
				  (relating to family planning clinic services).
(7) Chapter 1251 (relating to funeral
				  directors' services).
(8) Chapter
				  1229 (relating to health maintenance organization services).
(9) Chapter 1249 (relating to home health
				  agency services).
(10) Chapter 1123
				  (relating to medical supplies).
(11) Chapter 1147 (relating to optometrists'
				  services).
(12) Chapter 1243
				  (relating to outpatient laboratory services).
(13) Chapter 1153 (relating to outpatient
				  psychiatric services).
(14) Chapter
				  1121 (relating to pharmaceutical services).
(15) Chapter 1141 (relating to physicians'
				  services).
(16) Chapter 1143
				  (relating to podiatrists' services).
(17) Chapter 1129 (relating to rural health
				  clinic services).
(18) Chapter 1102
				  (relating to shared health facilities).
(19) Chapter 1230 (relating to portable x-ray
				  services).
(20) Chapter 1142
				  (relatinig to midwives' services).
(21) Chapter 1181 (relating to nursing
				  facility care).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › GENERAL PROVISIONS › Section 1102.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter sets forth the Medical Assistance regulations
					 and policies which apply to shared health facilities. The purpose of this
					 chapter is to eliminate fraudulent, abusive and deceptive conduct and practices
					 that may occur in shared health facilities. Shared health facilities are
					 subject to this chapter and Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › GENERAL PROVISIONS › Section 1102.2 - 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:
Administrator
-An individual designated by
					 a shared health facility operator to handle day-to-day operations of the
					 facility.
Department
-The Department of Public
					 Welfare of the Commonwealth.
Medical care
-Services or items covered
					 under the Medical Assistance Program.
Operator
-The person responsible for the
					 central coordination and management of the activities of a shared health
					 facility and for the compliance by the facility with applicable State
					 law.
Practitioner
-A medical doctor, doctor of
					 osteopathy, dentist, optometrist, podiatrist, chiropractor or other medical
					 professional who is licensed by the Commonwealth or by another state and is
					 enrolled in the Medical Assistance Program.
Provider
-An individual or medical facility
					 which signs an agreement with the Department to participate in the Medical
					 Assistance Program, including, but not limited to: licensed practitioners,
					 pharmacies, hospitals, nursing homes, clinics, home health agencies and medical
					 purveyors.
Public clinic
-A health clinic operated by
					 a Federal, State or local governmental agency.
Purveyor
-A person other than a
					 practitioner who, directly or indirectly, engages in the business of supplying
					 to patients medical supplies, equipment or services for which reimbursement
					 under the Medical Assistance Program is received, including, but not limited
					 to: clinical laboratory services or supplies, X-ray laboratory services or
					 supplies, inhalation therapy services or equipment, ambulance services, sick
					 room supplies, physical therapy services or equipment and orthopedic or
					 surgical appliances or supplies.
Shared health facility
-An entity other
					 than a licensed or approved hospital facility, skilled nursing facility,
					 intermediate care facility, intermediate care facility for the mentally
					 retarded, rural health clinic, public clinic or Health Maintenance Organization
					 in which:
(i) Medical services, either
				  alone or together with support services, are provided at a single
				  location.
(ii) Services are
				  provided by three or more practitioners, two or more of whom are practicing
				  within different professions.
(iii)
				  Practitioners share common waiting areas, examining rooms, equipment,
				  supporting staff or records.
(iv)
				  At least one practitioner receives payment on a fee for service
				  basis.
(v) A provider received more
				  than $30,000 in payment from the Medical Assistance Program during the 12 month
				  period prior to the date of the initial or renewal application of the shared
				  health facility for registration in the Medical Assistance Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › GENERAL PROVISIONS › Section 1102.3 - Legal authority

Current through Register Vol. 54, No. 28, July 13, 2024
Shared health facilities are registered and regulated by
					 the Department of Human Services under Article XIV of the Public Welfare Code
					 (62
					 P. S. §§
											1401-1411).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › GENERAL PROVISIONS › Section 1102.4 - Role of shared health facilities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A shared health facility is recognized by
				  the Department as a source of common support services for providers
				  participating in the Medical Assistance Program who render medical care at the
				  facility to Medical Assistance recipients. The support services may include,
				  but are not limited to: buildings, parking areas, space and
				  utilities.
(b) The providers
				  rendering medical care at the shared health facility reimburse the facility for
				  the cost of the support services it furnishes.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › SHARED HEALTH FACILITY REGISTRATION REQUIREMENTS › Section 1102.21 - Registration procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Upon
				  notification by the Department that the facility has been determined to be a
				  shared health facility, the operator of the shared health facility shall:
(1) Sign and submit to the Department two
				  copies of the Shared Health Facility Provider Agreement.
(2) Register the shared health facility with
				  the Department and specify the support and medical services to be provided at
				  the facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › ADMINISTRATIVE RESPONSIBILITIES OF OPERATORS › Section 1102.31 - General responsibilities

Current through Register Vol. 54, No. 28, July 13, 2024
The operator of a shared health facility is responsible for
					 the overall management and operation of the shared health facility and for
					 insuring the quality, continuity and proper coordination of medical care
					 provided by providers at the shared health facility to Medical Assistance
					 recipients. The operator shall, accordingly, comply with §§
										1102.32,
					 1102.33 and
					 1102.34 (relating to
					 responsibilities relating to shared health facility management;
					 responsibilities relating to the provision of medical services; and
					 responsibilities relating to provider performance).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › ADMINISTRATIVE RESPONSIBILITIES OF OPERATORS › Section 1102.32 - Responsibilities relating to shared health facility management

Current through Register Vol. 54, No. 28, July 13, 2024
The operator of a registered shared health facility shall:
(1) Apply, upon notification by the
				  Department that the facility has been determined to be a shared health
				  facility, for an initial registration and for renewal of the registration
				  annually thereafter.
(2) Insure
				  that accurate and complete information and documentation are furnished on the
				  application for registration of the shared health facility.
(3) Designate an administrator and hold the
				  administrator responsible for handling the day-to-day operations of the shared
				  health facility and supervise the activities of the administrator to insure
				  that the shared health facility is properly operated.
(4) Insure that providers at the shared
				  health facility will practice without influence by the operator or
				  administrator or both.
(5) Insure
				  that the administrative requirements and minimum care standards under this
				  chapter are being met continuously by the shared health facility and its
				  providers.
(6) Notify the
				  Department of the termination of the services of an operator, administrator or
				  of a provider in the shared health facility within 15 days of the date of
				  termination. The notice shall include:
(i)
				  The professional qualifications of an individual newly appointed to assume the
				  position of administrator.
(ii) The
				  professional license number of a provider newly participating in the
				  facility.
(iii) For either the
				  administrator or provider:
(A) The
				  name.
(B) Social security
				  number.
(C) Residence
				  address.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › ADMINISTRATIVE RESPONSIBILITIES OF OPERATORS › Section 1102.33 - Responsibilities relating to the provision of medical services

Current through Register Vol. 54, No. 28, July 13, 2024
The operator of a registered shared health facility shall:
(1) Insure that a recipient is
				  treated by a practitioner who is familiar with the medical history of the
				  recipient.
(2) Assign a clearly
				  identified general practitioner to each recipient, the assignment of whom may
				  be changed at any time at the request of the recipient.
(3) Insure the freedom of the recipient to
				  choose a provider at the shared health facility or elsewhere.
(4) Post conspicuously the names and
				  scheduled office hours of practitioners rendering services in the
				  facility.
(5) Make available to
				  patients either the telephone number of the central answering service of the
				  designated practitioner of the recipient or of the colleague of the
				  practitioner as designated by the practitioner or the telephone number of a
				  centralized 24-hour-a-day, 7 day-a-week answering service for recipient
				  off-hour questions.
(6) Maintain a
				  central registry that contains a daily record of the name and Medical
				  Assistance record number of each recipient receiving services at the facility,
				  the major complaint of each recipient and the name of a provider the services
				  of whom were requested by the recipient or to whom the recipient was
				  referred.
(7) Through the
				  administrator, insure that recipient records and summaries of all recipient
				  visits include the diagnosis and any pharmaceuticals prescribed and are at all
				  times available at either the facility or at a place immediately available to
				  all providers at the facility.
(8)
				  Insure that the physical facilities of the shared health facility provide
				  privacy for each recipient during examination, interview and treatment and that
				  the treatment rooms, equipment and medical supplies and instruments are clean
				  and properly maintained at all times.
(9) Post conspicuously the telephone number
				  of the Bureau of Utilization Review of the Office of Medical Assistance along
				  with a statement that the Bureau is responsible for providing information
				  concerning shared health facilities and for receiving complaints concerning the
				  provision of health care services at shared health facilities.
This section cited in 55 Pa. Code §
												1102.31 (relating to general
						responsibilities).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › ADMINISTRATIVE RESPONSIBILITIES OF OPERATORS › Section 1102.34 - Responsibilities relating to provider performance

Current through Register Vol. 54, No. 28, July 13, 2024
The operator of a shared health facility shall insure,
					 either directly or through the administrator, that providers rendering services
					 to recipients at a shared health facility and persons employed by the facility
					 shall:
(1) Refer a recipient to
				  another provider located inside or outside the shared health facility only when
				  there is medical justification for the referral and the medical records of the
				  referring practitioner clearly set forth the medical justification for the
				  referral.
(2) Whenever treating a
				  recipient referred by another provider inside or outside the shared health
				  facility, communicate in writing to the referring practitioner the diagnostic
				  evaluation and therapy rendered and incorporate this information into the
				  record of the recipient.
(3) Obtain
				  the signature of the recipient on outpatient orders or prescriptions written
				  for the recipient by practitioners at a shared health facility.
(4) Maintain proper recipient records, for a
				  minimum of 4 years, which contain at least:
(i) The full name, address and Medical
				  Assistance record number of each recipient.
(ii) The dates of visits by a recipient to
				  providers in the shared health facility and a statement as to whether the
				  recipient is instructed to return for further treatment and the dates of return
				  visits.
(iii) The major complaint
				  and diagnostic impressions for each visit to a provider in the shared health
				  facility.
(iv) Pertinent history
				  and physical examinations rendered by each provider in the shared health
				  facility;
(v) A listing of
				  medications prescribed by a provider in the shared health facility.
(vi) The precise dosage and prescription
				  regimens for each medication prescribed by a provider in the shared health
				  facility.
(vii) Orders for X-rays,
				  laboratory work and diagnostic tests written by or under the direction of a
				  provider at the shared health facility.
(viii) The results of the tests ordered under
				  subparagraph (vii).
(ix) The
				  medical documentation justifying the necessity of diagnostic procedures ordered
				  by a practitioner in a shared health facility regardless of whether the
				  procedure is performed directly by the onlining practioner or by someone under
				  the direct supervision of the practitioner or is referred to another practioner
				  or purveyor.
(x) Referrals by
				  practitioners in the shared health facility to other providers and the reasons
				  for the referrals.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › ADMINISTRATIVE RESPONSIBILITIES OF OPERATORS › Section 1102.34a - Clarification of the term "written"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term "written" in §
										1102.34(3) 
				  (relating to responsibilities relating to provider performance) includes orders
				  and prescriptions that are handwritten or transmitted by electronic
				  means.
(b) Written orders and
				  prescriptions transmitted by electronic means must be electronically encrypted
				  or transmitted by other technological means designed to protect and prevent
				  access, alteration, manipulation or use by any unauthorized person.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › PROVIDER PARTICIPATION › Section 1102.41 - Provider participation and enrollment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Providers at a registered shared health
				  facility shall enroll and participate individually in the Medical Assistance
				  Program in accordance with Chapter 1101 (relating to general provisions) and
				  the appropriate separate chapters relating to each provider type.
(b) Providers at a registered shared health
				  facility shall comply with Chapter 1101, the applicable provisions of this
				  chapter and the provisions contained in the appropriate separate chapters
				  relating to each provider type.
This section cited in 55 Pa. Code §
												1101.41 (relating to provider
						participation and registration of shared health
						facilities)
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › PAYMENT FOR SERVICES › Section 1102.51 - Reimbursement policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for
				  services provided to Medical Assistance recipients is made by the Department
				  directly to providers in a registered shared health facility. Payment is not
				  made to another payee including the shared health facility.
(b) Payment is made to a provider only if the
				  provider renders the service directly or if an employe of the provider renders
				  the service under the direct supervision of the provider. For example, if a
				  practitioner orders an X-ray and the X-ray is taken by someone other than the
				  practitioner or an employe of the practitioner under the direct supervision of
				  the practitioner, payment is not made to the practitioner for the ordered
				  services.
(c) Payment is made only
				  to enrolled physicians for radiology services and to enrolled laboratories for
				  laboratory services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › UTILIZATION CONTROL › Section 1102.61 - Inspection by the Department

Current through Register Vol. 54, No. 28, July 13, 2024
The Department may inspect the premises, business records,
					 recipient records, leases and other contracts executed by the operator or a
					 provider in a shared health facility. The inspections may be onsite visits to
					 the shared health facility.
This section cited in 55 Pa. Code §
												1101.51 (relating to ongoing
						responsibilities of providers).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1102 - SHARED HEALTH FACILITIES › UTILIZATION REVIEW › Section 1102.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the Medical Assistance
					 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 1121 - PHARMACEUTICAL SERVICES › GENERAL PROVISIONS › Section 1121.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for medically necessary
					 pharmaceutical services furnished directly to eligible recipients by pharmacies
					 enrolled as providers in the program. Payment for these services are subject to
					 this chapter and Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › COVERED AND NONCOVERED SERVICES › Section 1121.11 - Types of services covered

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  The MA Program covers legend drugs except as otherwise specified in this
				  chapter if the medical necessity has been established and the drug has been
				  prescribed or ordered by a licensed prescriber within the scope of the
				  prescriber's practice.
(b) The MA
				  Program covers the nonlegend drugs specified in §
										1121.53(d)
				  (relating to limitations on payment), except that for GA recipients, coverage
				  of nonlegend drugs is limited to insulin and drugs that the Department has
				  identified as the preferred drug in a therapeutic class.
(c) Payment is subject to the conditions and
				  limitations of this chapter and Chapter 1101 (relating to general
				  provisions).
The provisions of this §
												1121.11 amended under sections
						201(2), 403(b), 443.4 and 454 of the Public Welfare Code (62 P. S. §§
													201(2),
						403(b), 443.4 and
						454).
This section cited in 55 Pa. Code §
												1124.24 (relating to scope of
						benefits for GA recipients).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › COVERED AND NONCOVERED SERVICES › Section 1121.12 - Outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
Outpatient pharmaceutical services are only covered when
					 provided in accordance with this chapter and Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › SCOPE OF BENEFITS › Section 1121.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for medically
					 necessary pharmaceutical services covered by the MA Program, subject to the
					 conditions and limitations of this chapter.