reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › PROVIDER PARTICIPATION › Section 1225.43 - Additional requirements for independent family planning clinics

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements listed in
					 §
										1225.41 (relating to general
					 participation requirements) independent family planning clinics shall meet the
					 following participation requirements:
(1) Provide services either directly by a
				  physician or under the supervision of a physician. This means that one or more
				  physicians shall be on staff to either provide directly or supervise the
				  provision of service. If a physician does not provide services directly, then:
(i) The services shall be provided by a
				  certified registered nurse practitioner, a physician assistant or a registered
				  nurse, as appropriate, on the basis of a predetermined plan of diagnosis and
				  treatment that has been approved by a physician.
(ii) A physician shall be immediately
				  available through direct communication or by radio, telephone or
				  telecommunications.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › PROVIDER PARTICIPATION › Section 1225.44 - Participation requirements for out-of-State family planning clinics

Current through Register Vol. 54, No. 28, July 13, 2024
Out-of-State family planning clinics shall meet the
					 requirements set forth in §
										1101.42(b)
					 (relating to prerequisites for participation).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › PROVIDER PARTICIPATION › Section 1225.45 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
Ongoing responsibilities of providers are established in
					 Chapter 1101 (relating to general provisions).
This section cited in 55 Pa. Code §
												1225.41 (relating to general
						participation requirements).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › PAYMENT FOR FAMILY PLANNING CLINIC SERVICES › Section 1225.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for services provided by or under the
					 supervision of a physician in a hospital outpatient family planning clinic, or
					 independent family planning clinic, subject to the conditions and limitations
					 set forth in 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 1225 - FAMILY PLANNING CLINIC SERVICES › PAYMENT FOR FAMILY PLANNING CLINIC SERVICES › Section 1225.52 - Conditions of payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Family
				  planning services shall be provided either by, or under the supervision of a
				  physician.
(b) Family planning
				  services shall be provided at the clinic site.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › PAYMENT FOR FAMILY PLANNING CLINIC SERVICES › Section 1225.54 - Noncompensable family planning services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made to a family planning clinic for
					 the following services regardless of where or to whom they are provided:
(1) Services and procedures that are
				  available through other public agencies, private insurance plans, and State or
				  Federal Programs, except Titles V, X, XX, and the Indochinese Refugee
				  Assistance Act.
(2) Procedures not
				  listed in the MA Program fee schedule or the fee schedule promulgated by the
				  Family Planning Division of the Department.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › UTILIZATION CONTROL › Section 1225.71 - 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 1225 - FAMILY PLANNING CLINIC SERVICES › ADMINISTRATIVE SANCTIONS › Section 1225.81 - 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 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › GENERAL PROVISIONS › Section 1229.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The Medical Assistance Program provides payment for
					 specific medically necessary services rendered to eligible recipients by Health
					 Maintenance Organizations (HMOs) enrolled as providers under the program.
					 Payment for services provided by HMOs is subject to this chapter and Chapter
					 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › GENERAL PROVISIONS › Section 1229.2 - 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:
Health Maintenance Organization (HMO)
-A
					 legal entity determined by the Assistant Secretary for Health, Department of
					 Health and Human Services, to be organized and operated in the manner
					 prescribed in section 1301(c) of the Social Security Act (42 U.S.C.A. §
											300e(c)) and which provides,
					 in the manner prescribed by section 1301(b) of the Social Security Act
					 (42 U.S.C.A. §
											300e(b)) at least the
					 following health services to its eligible enrollees:
(i) Inpatient hospital services.
(ii) Outpatient services.
(iii) Laboratory and X-ray
				  services.
(iv) Family planning
				  services and supplies.
(v)
				  Physician services.
(vi) Home
				  health services for individuals entitled to those services under the Medicaid
				  State Plan.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › SCOPE OF BENEFITS › Section 1229.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients enrolled in a Health
					 Maintenance Organization (HMO) are eligible for the full range of HMO services
					 covered by the contract of the Department with the HMO. The recipient shall be
					 informed of the services the HMO provides at the time he enrolls.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › SCOPE OF BENEFITS › Section 1229.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients enrolled in a Health Maintenance
					 Organization (HMO) are eligible for the full range of HMO services covered by
					 the contract of the Department with the HMO. The recipient shall be informed of
					 the services the HMO provides at the time he enrolls.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › SCOPE OF BENEFITS › Section 1229.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients enrolled in a Health
					 Maintenance Organization (HMO) are eligible for the full range of HMO services
					 covered by the contract of the Department with the HMO. The recipient shall be
					 informed of the services the HMO provides at the time he enrolls.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › PROVIDER PARTICIPATION › Section 1229.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements established
					 in Chapter 1101 (relating to general provisions), Health Maintenance
					 Organizations (HMOs) shall meet the following participation requirements:
(1) Have signed a contract with the
				  Office of Medical Assistance for provision of HMO services to Medical
				  Assistance eligibles.
(2) Comply
				  with applicable Federal and State laws and regulations including but not
				  limited to, Title XIX of the Social Security Act (42 U.S.C.A. §§
											1396-1396k); Article IV of the Public
				  Welfare Code (62 P. S. §§
											401-489), and, when applicable, the Voluntary
				  Nonprofit Health Service Act of 1972 (40 P. S. §§
											1551-1557).
(3) Have arrangements with other providers
				  for referring recipients for services for which they are eligible under the
				  Medical Assistance Program but which are not provided by the HMO.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › PAYMENT FOR HEALTH MAINTENANCE ORGANIZATION SERVICES › Section 1229.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment for Health Maintenance Organization (HMO) services is made according to
				  a capitation rate which is negotiated by the Department with each participating
				  HMO. The Department will negotiate contracts with qualified HMOs in accordance
				  with the established policy of the Commonwealth for competitive bidding and in
				  accordance with applicable Federal regulations. A model contract shall be made
				  available to a Federally qualified HMO that desires to provide services to
				  Medical Assistance eligible recipients.
(b) No payment will be made to providers
				  other than the HMO for services rendered to an enrolled recipient if the
				  services were available to the recipient under the contract.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › UTILIZATION CONTROL › Section 1229.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Claims submitted for payment under the
				  Medical Assistance Program are subject to the utilization control procedures
				  established in Chapter 1101 (relating to general provisions). Providers shall
				  fully cooperate with audits and reviews made by the Department for the purpose
				  of determining the validity of claims, the reasonableness and necessity of
				  services provided and charges made to the general public.
(b) The Health Maintenance Organization (HMO)
				  contractor shall cooperate fully with the Office of Medical Assistance or its
				  authorized agents in exercising the responsibility of the Department to conduct
				  periodic medical audits under Federal regulations at
				  42 CFR
				  431.543.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES › ADMINISTRATIVE SANCTIONS › Section 1229.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with the Medical Assistance 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 contract of the
					 provider, are subject to the sanctions imposed in Chapter 1101 (relating to
					 general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › GENERAL PROVISIONS › Section 1230.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program covers the technical components for specific
					 radiological and cardiovascular services rendered to eligible recipients by
					 approved organizations enrolled as providers under the program. The service
					 shall be ordered by a licensed practitioner and the medical necessity for the
					 service shall be established. Payment for portable X-ray services is subject to
					 this chapter, Chapter 1101 (relating to general provisions) and the limitations
					 established in Chapter 1150 (relating to MA Program payment policies) and the
					 MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › SCOPE OF BENEFITS › Section 1230.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for the full
					 range of portable X-ray services compensable under the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › SCOPE OF BENEFITS › Section 1230.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for the full range
					 of portable X-ray services compensable under the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › SCOPE OF BENEFITS › Section 1230.23 - 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
					 portable X-ray services unless they are also either categorically or medically
					 needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › SCOPE OF BENEFITS › Section 1230.24 - 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 § 1101.3(e) (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › PROVIDER PARTICIPATION › Section 1230.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements established
					 in Chapter 1101 (relating to general provisions), portable X-ray providers
					 shall meet the participation requirements of this section:
(1) Portable X-ray providers shall be
				  currently Medicare certified or currently certified by the Department of Health
				  as meeting standards comparable to those of Medicare.
(2) Portable X-ray equipment shall be
				  inspected and registered in accordance with the provisions of 25 Pa. Code Part
				  I, Subpart D, Article V (relating to radiological health).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › PROVIDER PARTICIPATION › Section 1230.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Providers shall meet the ongoing
				  responsibilities of this section in addition to the ongoing responsibilities
				  established in §
										1101.51 (relating to ongoing
				  responsibilities of providers).
(b)
				  State and Federal officials or their authorized agents may conduct onsite
				  reviews in order to verify information furnished as a basis for payment under
				  the MA Program and to establish the provider's usual and customary charge to
				  the general public, as defined in Chapter 1101 (relating to general
				  provisions). Reviews shall be conducted during normal hours of operation or at
				  a time mutually agreeable to the officials and the providers. During the course
				  of the review, the provider shall ensure that the reviewers have access to, and
				  are permitted to photograph, photocopy or duplicate:
(1) X-ray films and reports of studies
				  performed and billed to the Department.
(2) Procedure manuals, records and documents
				  necessary to determine whether payment for services is or was due under the
				  program and whether services are or were provided in compliance with State and
				  Federal law.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › PAYMENT FOR PORTABLE X-RAY SERVICES › Section 1230.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered services provided by
					 participating providers to eligible recipients in the patients' home and in
					 skilled nursing and intermediate care facilities, subject to the conditions and
					 limitations established in this chapter and Chapters 1101 and 1150 (relating to
					 general provisions; and MA Program payment policies) and the MA fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › PAYMENT FOR PORTABLE X-RAY SERVICES › Section 1230.52 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Portable X-ray procedures billed to the
				  Department shall be based on a practitioner's written request. The written
				  request must include:
(1) The practitioner's
				  name and medical license number.
(2) The recipient's name and
				  address.
(3) The recipient's case
				  number.
(4) The date of the
				  request.
(5) The handwritten
				  signature of the practitioner or the practitioner's designated
				  employe.
(6) The number and type of
				  X-ray studies requested.
(7) The
				  diagnosis or reason the X-rays were ordered.
(8) The reasons for the need for portable
				  X-ray study rather than office X-ray.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › PAYMENT FOR PORTABLE X-RAY SERVICES › Section 1230.52a - Clarification of the terms "written" and "signature"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term
				  "written" in §
										1230.52(a) 
				  (relating to payment conditions for various services) includes requests for
				  portable X-ray procedures that are handwritten or transmitted by electronic
				  means.
(b) Written requests
				  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.
(c) The term "signature" in §
										1230.52(a)(5)
				  includes a handwritten or electronic signature that is made in accordance with
				  the Electronic Transaction Act (73 P. S. §§
											2260.101-2260.5101).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › PAYMENT FOR PORTABLE X-RAY SERVICES › Section 1230.53 - Limitation on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For
				  all portable X-ray services, the provider's maximum payment is the lowest of:
(1) The provider's usual and customary charge
				  to the general public.
(2) The
				  upper limits set by Medicare or Medicaid.
(3) The maximum fees or rates established in
				  the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › PAYMENT FOR PORTABLE X-RAY SERVICES › Section 1230.54 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made to any portable X-ray provider
					 for:
(1) Procedures not listed in the
				  MA Program fee schedule.
(2)
				  Services provided to a hospitalized recipient, including a recipient in a
				  psychiatric hospital.
(3) Services
				  provided to a recipient in a licensed practitioner's office.
(4) Routine screening such as an examination
				  without a diagnosis or suspected medical condition.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1230 - PORTABLE X-RAY SERVICES › UTILIZATION REVIEW › Section 1230.71 - Scope of claim 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 1230 - PORTABLE X-RAY SERVICES › ADMINISTRATIVE SANCTIONS › Section 1230.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers who bill for service inconsistent with MA Program
					 regulations, provide service outside the scope of customary standards of
					 practice, or otherwise violate 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 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › GENERAL PROVISIONS › Section 1241.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for EPSDT services rendered
					 to eligible recipients by practitioners enrolled as providers under the
					 program. Payment for EPSDT services is subject to this chapter, Chapter 1101
					 (relating to the general provisions) and the limitations established in Chapter
					 1150 (relating to MA Program payment policies) and the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › GENERAL PROVISIONS › Section 1241.2 - 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:
Administrative contractor
-A nonprofit
					 organization engaged in health care management that has contracted with the
					 Department to be responsible for the coordination of existing, and the
					 development of new screening resources to serve the eligible population in
					 assigned geographical areas. The administrative contractor shall be accountable
					 to the Department for the quality of services rendered and for fulfilling other
					 responsibilities specified in this chapter.
EPSDT Program
-Early and Periodic
					 Screening, Diagnosis and Treatment Program.
Eligible Child
-An individual 20 years of
					 age or younger who is eligible for a Public Assistance cash grant or
					 Supplemental Security Income (SSI) or an individual 20 years of age or younger
					 who does not receive a cash grant and whose annual income and resources do not
					 exceed certain limits based on family size.
Screening
-The direct provision of testing
					 and evaluation services provided by certified EPSDT screening providers for
					 eligible children in order to ascertain diseases or abnormalities requiring
					 diagnosis and treatment.
Screening provider
-A licensed physician, a
					 group of licensed physicians or an appropriate agency such as a hospital,
					 health center or health department which uses the services of licensed
					 physicians. The provider shall be able to provide either directly or through
					 referral facets of general pediatric services to MA and non-MA
					 children.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › SCOPE OF BENEFITS › Section 1241.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients under age 21 are eligible
					 for EPSDT screening services listed in Appendix A (relating to screening
					 services required examinations and diagnostic tests) in addition to the
					 services for which they are ordinarily eligible as categorically needy
					 recipients. Categorically needy individuals screened under this chapter are
					 also eligible for hearing aids and eyeglasses.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › SCOPE OF BENEFITS › Section 1241.22 - Scope of benefits for medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients under age 21 are eligible for
					 EPSDT screening services listed in Appendix A (relating to screening services
					 required examinations and diagnostic tests) in addition to the services for
					 which they are ordinarily eligible as medically needy recipients. Medically
					 needy recipients screened under this chapter are also eligible for hearing
					 aids, eyeglasses and dentists' services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › SCOPE OF BENEFITS › Section 1241.23 - 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 EPSDT
					 services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › PROVIDER PARTICIPATION › Section 1241.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements established
					 in Chapter 1101 (relating to general provisions), screening providers are
					 required, as a condition of participation, to have a written agreement with the
					 Department as to the screening services to be provided and the rate of payment.
					 Screening providers shall also have a current MA outpatient provider agreement
					 and be certified as a screening provider by the Office of MA.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › PROVIDER PARTICIPATION › Section 1241.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the ongoing responsibilities of providers
					 established in Chapter 1101 (relating to general provisions), screening
					 providers shall be responsible for the following:
(1) If the screening provider is not licensed
				  or equipped to render the necessary treatment or further diagnosis, the
				  screening provider shall refer the individual to an appropriate enrolled
				  practitioner or facility, or to the CAO for supportive help in locating an
				  appropriate provider.
(2)
				  Immunizations shall be updated and recorded during EPSDT screening. The
				  physician's records shall show as much immunization history as can be provided
				  by the physician and the parents. Standard immunization guidelines, and
				  amendments thereof, will be issued and published by the Department through a
				  Class II Bulletin based on recommendations of recognized medical and dental
				  organizations involved in child health care.
The provisions of this §
												1241.42 amended sections 403(a)
						and (b) and 443.3(1) and (2) of the Public Welfare Code (62 P. S.
						§§
													403(a) and (b)
						and 443.3(1) and
						(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › PAYMENT FOR EPSDT SCREENING › Section 1241.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will make all payments to the participating
					 screening provider.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › PAYMENT FOR EPSDT SCREENING › Section 1241.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment for screening will be made no more frequently than specified in the MA
				  Program fee schedule:
(b) The
				  Department will make payment for immunizations approved by the Federal Drug
				  Administration (FDA), when used as approved by the FDA, and as listed in the
				  Department's pricing service.
The provisions of this §
												1241.53 amended under sections
						403(a) and (b) and 443.3(1) and (2) of the Public Welfare Code (62 P. S.
						§§
													403(a) and (b)
						and 443.3(1) and (2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › PAYMENT FOR EPSDT SCREENING › Section 1241.54 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment will not be made for the
				  following:
(1) Screens that do not include
				  the appropriate tests in Appendix A (relating to screening services required
				  examinations and diagnostic tests).
(2) General health care provided during an
				  EPSDT screening examination visit.
(3) A medical examination performed on the
				  same day as the screen.
(4)
				  Invoices not submitted to the billing contractor within 30 days of the
				  screening examination. Invoices received after 30 days will be
				  returned.
(5) Laboratory tests that
				  are included in the screening fee.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › UTILIZATION CONTROL › Section 1241.71 - 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 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › ADMINISTRATIVE SANCTIONS › Section 1241.81 - 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 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 1241 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM › ADMINISTRATIVE SANCTIONS › Appendix A - SCREENING SERVICES REQUIRED EXAMINATIONS AND DIAGNOSTIC TESTS

Current through Register Vol. 54, No. 28, July 13, 2024
The screening of an eligible MA recipient shall include the
					 following examinations, evaluations and appropriate diagnostic tests as
					 specified per age group.
(1)
Individuals
-
Birth Through 18
					 Months
(i) Taking a health history from the parent or
					 guardian.
(ii) Unclothed physical examination.
(iii) Developmental Appraisal-Denver or equivalent.
(iv) Growth Measurements.
(v) Metabolic Screening-PKU when appropriate.
(vi) Anemia Screening-Hemoglobin and/or Hematocrit when
					 appropriate.
(vii) Lead Poisoning Evaluation when appropriate.
(viii) Sickle Cell Anemia Evaluation when
					 appropriate.
(ix) Tuberculosis Testing when appropriate.
(x) Assessing and updating appropriate
					 immunizations.
(2)
Individuals
-
19 Months Through
					 Age 20
(i) Taking of a health history from the parent.
(ii) Unclothed physical examination, including Tanner Score
					 and blood pressure.
(iii) Developmental Appraisal.
(iv) Vision Test.
(v) Hearing Test.
(vi) Dental Examination.
(vii) Urine Screen for bacteria, sugar, albumin.
(viii) Malnutrition Evaluation.
(ix) Tuberculosis Testing when appropriate.
(x) Iron Anemia-Hemoglobin and Hematocrit when
					 appropriate.
(xi) Lead Poisoning Evaluation when appropriate.
(xii) Sickle Cell Anemia Evaluation when
					 appropriate.
(xiii) Assessing and updating appropriate immunizations
					 when required.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › Section 1243.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific outpatient
				  laboratory services rendered to eligible recipients by laboratories enrolled as
				  providers under the Program. Payment for outpatient laboratory services 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.
The provisions of this section are amended under sections
					 201(2), 403 and 443.3 of the Public Welfare Code (62 P. S. §§
												201(2),
					 403 and
					 443.3).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › Section 1243.2 - 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:
CLIA
-The Clinical Laboratory Improvement
				  Amendments of 1988 (42
				  U.S.C.A. §
										263a.
Laboratory
-A facility for the biological,
				  microbiological, serological, chemical, immunohema-tological, hematological,
				  biophysical, cytological, pathological or other examination of materials
				  derived from the human body for the purpose of providing information for the
				  diagnosis, prevention or treatment of any disease or impairment of, or the
				  assessment of the health of, human beings. These examinations also include
				  procedures to determine, measure or otherwise describe the presence or absence
				  of various substances or organisms in the body. Facilities only collecting or
				  preparing specimens, or both, or only serving as a mailing service and not
				  performing testing are not considered laboratories.
Panel test
-A series of diagnostically
				  related laboratory tests ordered by a practitioner to confirm a presumptive
				  diagnosis.
The provisions of this section are amended under sections
					 201(2), 403 and 443.3 of the Public Welfare Code (62 P. S. §§
												201(2),
					 403 and
					 443.3).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › SCOPE OF BENEFITS › Section 1243.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for the
					 outpatient laboratory services listed in the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › SCOPE OF BENEFITS › Section 1243.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for the outpatient
					 laboratory services listed in the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › SCOPE OF BENEFITS › Section 1243.23 - 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
					 outpatient laboratory services unless they are also either categorically or
					 medically needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › SCOPE OF BENEFITS › Section 1243.24 - 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 1243 - OUTPATIENT LABORATORY SERVICES › PROVIDER PARTICIPATION › Section 1243.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements established
					 in Chapter 1101 (relating to general provisions) laboratories shall meet the
					 following requirements:
(1) Each
				  laboratory, whether in or out-of-State, shall submit the following to the
				  Department:
(i) A copy of its CLIA
				  certificate.
(ii) A copy of its
				  CLIA identification number.
(iii) A
				  list of diagnostic procedures that the laboratory is CLIA-certified to perform
				  with the corresponding Healthcare Common Procedure Coding System (HCPCS)
				  codes.
(iv) The fee currently
				  charged to the general public for each of the procedures.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › PROVIDER PARTICIPATION › Section 1243.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the ongoing responsibilities established in
					 §
										1101.51(a)-(e)
					 (relating to ongoing responsibilities of providers), laboratories shall, as a
					 condition of participation, comply with the following requirements:
(1) Promptly report to the Department changes
				  in the laboratory's CLIA certification, including changes in the type of CLIA
				  certificate, changes in laboratory fees or procedures and the effective date of
				  these changes.
(2) Permit
				  authorized State and Federal officials or their authorized agents to conduct
				  onsite reviews for the purpose of verification of information furnished as a
				  basis for payment under the MA Program. During the course of the review, the
				  reviewers shall be allowed access to the laboratory area. The provider shall
				  also allow reviewers access to laboratory procedure manuals and any records or
				  documents necessary to determine whether payment for services that have or are
				  being provided comply with Federal and State laws and regulations. The
				  reviewers shall be allowed to photograph, photocopy or duplicate the manuals,
				  records, and documents. Onsite reviews shall be conducted during the normal
				  hours of operation or at another time mutually agreeable to the officials and
				  the provider.
(3) Laboratories
				  shall avoid locked-in referral arrangements between themselves and a
				  prescriber.
The provisions of this section are amended under sections
						201(2), 403 and 443.3 of the Public Welfare Code (62 P. S. §§
													201(2),
						403 and
						443.3).
This section cited in 55 Pa. Code §
												1243.71 (relating to scope of
						claims review procedures).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › PAYMENT FOR OUTPATIENT LABORATORY SERVICES › Section 1243.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered services provided by
					 participating laboratories subject to the conditions and limitations
					 established in this section and §
										1243.53 (relating to limitations
					 on payment) 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 1243 - OUTPATIENT LABORATORY SERVICES › PAYMENT FOR OUTPATIENT LABORATORY SERVICES › Section 1243.52 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If a laboratory refers work to another
				  laboratory, payment will be made to either the referring laboratory or the
				  laboratory actually performing the test. Payment will be made only if the
				  laboratory billing the Department is currently participating in the MA Program
				  and has listed the diagnostic procedure being billed with the Department as
				  specified in §
										1243.41(1)
				  (relating to participation requirements).
(b) Laboratory procedures billed to the
				  Department will be based on a written request of the practitioner. The written
				  request must include the following:
(1) The
				  name of the practitioner, the Medical Assistance Identification (M.A.I.D.)
				  number of the practitioner or the DEA number of the practitioner.
(2) The name of the recipient.
(3) The case number of the
				  recipient.
(4) The date of the
				  request.
(5) The handwritten
				  signature of the practitioner or the designee of the
				  practitioner.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › PAYMENT FOR OUTPATIENT LABORATORY SERVICES › Section 1243.52a - Clarification of the terms "written" and "signature"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term
				  "written" in §
										1243.52(b) 
				  (relating to payment conditions for various services) includes requests for
				  laboratory procedures that are handwritten or transmitted by electronic
				  means.
(b) Written requests
				  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.
(c) The term "signature" in §
										1243.52(b)(5)
				  includes a handwritten or electronic signature that is made in accordance with
				  the Electronic Transaction Act (73 P. S. §§
											2260.101-2260.5101).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › PAYMENT FOR OUTPATIENT LABORATORY SERVICES › Section 1243.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  fees listed in the MA Program fee schedule are the maximum fees allowed under
				  the MA Program.
(b) Section
				  1903(i)(1) of Title XIX of the Social Security Act (42 U.S.C.A. §
											1396(i)(1)) provides that
				  charges allowed for medical services, supplies, and equipment under Medicare
				  Part B and Medicaid that, in the judgment of the Secretary of Health and Human
				  Services (HHS) do not generally vary significantly from one provider to
				  another, may not exceed the lowest charge levels at which the items and
				  services are widely and consistently available in a locality. Certain
				  laboratory procedures are presently subject to lowest charge levels. Other
				  procedures shall be added to the list by HHS from time to time. For those
				  selected procedures established by both Medicare and Medicaid, the lowest
				  charge level adopted by the Medicare carrier shall control. For those selected
				  procedures furnished only under Medicaid, the Department will set lowest charge
				  levels according to the procedures used by Medicare. Medical Assistance maximum
				  fees for laboratory procedures shall be periodically adjusted and published in
				  the
Pennsylvania Bulletin
under the act of July 31, 1968 (P.
				  L. 769, No. 240) (45 P. S. §§
											1102,
				  1201-1208 and
				  1602); and 45 Pa.C.S.
				  Chapters 5, 7 and 9, known as the Commonwealth Documents Law.
This section cited in 55 Pa. Code §
												1243.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › PAYMENT FOR OUTPATIENT LABORATORY SERVICES › Section 1243.54 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made to a laboratory for the following
					 services regardless of where or to whom they are provided:
(1) Procedures not listed in the fee schedule
				  in the MA Program fees schedule.
(2) Travel to a recipient's place of
				  residence to collect a specimen. The provider will be reimbursed for performing
				  the procedure if it is compensable; however, no extra payment will be made for
				  mileage.
(3) Procedures that the
				  laboratory is not CLIA-certified to perform.
The provisions of this section are amended under sections
						201(2), 403 and 443.3 of the Public Welfare Code (62 P. S. §§
													201(2),
						403 and
						443.3).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › UTILIZATION REVIEW › Section 1243.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the utilization review procedures
					 established in Chapter 1101 (relating to general provisions), the procedure
					 manual of the laboratory shall be available to the representatives of the
					 Department as specified in §
										1243.42(2)
					 (relating to ongoing responsibilities of providers).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1243 - OUTPATIENT LABORATORY SERVICES › ADMINISTRATIVE SANCTIONS › Section 1243.81 - 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 laboratory practice, or to have otherwise
					 violated the standard set forth in the provider agreement, are subject to the
					 sanctions imposed in Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1245 - AMBULANCE TRANSPORTATION › GENERAL PROVISIONS › Section 1245.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for ambulance
					 transportation rendered to eligible recipients by ambulance providers enrolled
					 in the program to provide BLS or ALS services, or both. Payment for ambulance
					 transportation is subject to this chapter, Chapter 1101 (relating to general
					 provisions) and the limitations established in Chapter 1150 (relating to MA
					 Program payment policies) and the MA Program fee schedule.