reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › COVERED SERVICES › Section 1130.63 - Limitations on coverage

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Nursing care may be covered on a continuous basis for as much as 24 hours a day
				  during periods of crisis as necessary to maintain the recipient at home.
				  Homemaker or home health aide services, or both, may be covered on a 24-hour
				  continuous basis during periods of crisis, but care during these periods shall
				  be predominantly nursing care as described by Medicare regulations at
				  42 CFR
				  418.202(a) (relating to
				  covered services).
(b) Respite care
				  may not exceed a total of 5 days in a 60-day certification period.
(c) Bereavement counseling is a required
				  hospice service but it is not reimbursable.
(d) General inpatient care shall be provided
				  in a general hospital, skilled nursing facility or a freestanding hospice
				  participating in the MA Program.
(e) An intermediate care facility may provide
				  only respite care services to the hospice. Eligible MA recipients residing in
				  an intermediate care facility may elect to receive care from a participating
				  hospice.
(f) Hospice providers may
				  arrange for respite care services only in those intermediate care facilities
				  that meet the Medicare regulations at
				  42 CFR
				  418.100(a) and (f) (relating
				  to condition of participation for freestanding hospices providing inpatient
				  care directly) regarding 24-hour nursing services and patient areas.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › PAYMENT FOR HOSPICE CARE › Section 1130.71 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment is made to a participating hospice in accordance with the coverage and
				  payment rates established by Medicare regulations at
				  42 CFR
				  418.302 (relating to payment procedures for
				  hospice care). Exceptions are as follows:
(1)
				  A recipient with a confirmed diagnosis of acquired immune deficiency syndrome
				  (AIDS) will not be counted when calculating the hospice inpatient care limit
				  established by Medicare regulations at
				  42 CFR
				  418.302(f).
(2) A hospice provider will not be subject to
				  the annual cap on overall payments as described by Medicare regulations at
				  42 CFR
				  418.309 (relating to hospice cap
				  amount).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › PAYMENT FOR HOSPICE CARE › Section 1130.72 - Payment for physicians' services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The following services performed by
				  hospice physicians are included in the level of care rates paid for a day of
				  hospice care:
(1) General supervisory
				  services of the medical director.
(2) Participation in the establishment of
				  plans of care, supervision of care and services, periodic review and updating
				  of plans of care and establishment of governing policies by the physician
				  member of the interdisciplinary group.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › PAYMENT FOR HOSPICE CARE › Section 1130.73 - Additional payment for nursing facility residents

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An additional payment is made to a
				  hospice for hospice care furnished to a MA recipient who is a resident of a
				  skilled or intermediate care facility participating in the MA Program. The
				  additional payment will take into account the cost of room and board. Room and
				  board rates will be calculated as follows:
(1) Room and board cost data will be
				  retrieved from the most recently audited cost reports of participating skilled
				  nursing facilities.
(2) Appropriate
				  inflation factors will be applied to each facility's room and board cost as
				  needed to bring it forward to Fiscal Year 1989-90.
(3) The costs will be grouped into
				  Metropolitan Statistical Areas (MSAs) according to the location of the nursing
				  facility.
(4) An average room and
				  board per diem will be calculated for each group.
(5) A wage index appropriate to each MSA will
				  be applied to the average room and board per diem to account for area
				  differences in wages.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › UTILIZATION CONTROL › Section 1130.81 - Scope of utilization review process

Current through Register Vol. 54, No. 28, July 13, 2024
Hospice services provided to MA recipients are subject to
					 the utilization review procedures established under Chapter 1101 (relating to
					 general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › ADMINISTRATIVE SANCTIONS › Section 1130.91 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
If the Department determines that a provider billed for
					 services inconsistent with this chapter and Chapter 1101 (relating to general
					 provisions), provided incorrect information on the billing invoice regarding a
					 recipient's diagnosis or the services provided during the period the recipient
					 was under the care of the hospice or otherwise violated the standards set forth
					 in the provider agreement, the provider is subject to the sanctions described
					 in Chapter 1101.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › RIGHT OF APPEAL › Section 1130.101 - Hospice right of appeal

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  hospice's right of appeal is set forth at Chapter 1101 (relating to general
				  provisions).
(b) Hospice providers
				  and hospice physicians do not have the right to separate appeals on the same
				  case.
(c) For cases undergoing the
				  appeal process, payment including adjustments will be withheld until the case
				  is adjudicated.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › RIGHT OF APPEAL › Appendix A

Current through Register Vol. 54, No. 28, July 13, 2024
Click to view
					 image
This appendix cited in 55 Pa. Code §
												1130.22 (relating to duration of
						coverage).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › RIGHT OF APPEAL › Appendix B

Current through Register Vol. 54, No. 28, July 13, 2024
Click to view
					 image
Click to view
					 image
This appendix cited in 55 Pa. Code §
												1130.41 (relating to election of
						hospice care).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › RIGHT OF APPEAL › Appendix C

Current through Register Vol. 54, No. 28, July 13, 2024
Click to view
					 image
This appendix cited in 55 Pa. Code §
												1130.41 (relating to election of
						hospice care).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1130 - HOSPICE SERVICES › RIGHT OF APPEAL › Appendix D

Current through Register Vol. 54, No. 28, July 13, 2024
Click to view
					 image
This appendix cited in 55 Pa. Code §
												1130.42 (relating to revocation of
						hospice care).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › GENERAL PROVISIONS › Section 1140.1 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for HBP services rendered
					 to eligible recipients by practitioners enrolled as qualified providers under
					 the Program. Payment for HBP 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 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › GENERAL PROVISIONS › Section 1140.2 - 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:
Care coordinator
-An individual employed by
					 the qualified provider to serve as the client's primary contact and facilitator
					 of multidisciplinary communication.
HBP-Healthy Beginnings PLUS Program
-An
					 enhanced, comprehensive package of prenatal and postpartum services provided to
					 eligible MA recipients by enrolled qualified providers.
HBP service
-A comprehensive package of
					 services for pregnant women consisting of the following:
(i) Basic services provided to clients
				  enrolled in HBP, including care coordination, medical and obstetrical,
				  nutritional, psychosocial and health promotion.
(ii) High risk maternity services provided to
				  individual clients in response to an identified medical or obstetrical risk
				  requiring services to be provided with greater frequency and of longer
				  duration.
(iii) Special services
				  provided to individual clients on as-needed basis, generally in response to an
				  identified medical or obstetrical, nutrition or psychosocial risk.
Qualified provider
-A provider or
					 practitioner formally enrolled in the HBP and designated as eligible to provide
					 HBP services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › SCOPE OF BENEFITS › Section 1140.21 - 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 HBP services compensable under the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › SCOPE OF BENEFITS › Section 1140.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for medically
					 necessary HBP services compensable under the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › SCOPE OF BENEFITS › Section 1140.23 - 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 HBP
					 services, unless they are also categorically or medically
					 needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › PROVIDER PARTICIPATION › Section 1140.41 - 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), HBP providers are required,
					 as a condition of participation, to have a current MA provider agreement. HBP
					 providers shall formally enroll in the HBP Program. To participate, HBP
					 providers shall have an approved qualified provider application and shall
					 satisfy the requirements contained in this section, consistent with the
					 implementation plan delineated in each provider's approved qualified provider
					 application.
(1) The qualified
				  provider, whether enrolled in the MA Program as a hospital obstetrical clinic,
				  community health center, migrant health center, rural health center, birthing
				  center, family planning clinic, home health agency or private obstetrical or
				  family practice, even if providing other types of medical care, have a
				  concentration of specialization in prenatal services.
(2) The qualified provider shall employ one
				  or more care coordinators who:
(i) Have had
				  clinical experience in maternity care.
(ii) Can determine nutrition risks of
				  applicants for the Pennsylvania Women, Infants and Children (WIC)
				  Program.
(iii) Are onsite during
				  the client's prenatal care visits to perform initial and periodic risk
				  assessments and timely health promotions.
(iv) Are available at the clinic to
				  coordinate all aspects of the client's care, including reinforcement of
				  postpartum health promotion that was initiated post delivery in the hospital;
				  that is, postpartum physical and psychological changes, lactation,
				  parent-infant care and interim family planning method information.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › PROVIDER PARTICIPATION › Section 1140.42 - 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).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › PAYMENT FOR HBP SERVICES › Section 1140.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered services provided by
					 participating HBP providers subject to the conditions and limitations
					 established in this chapter, Chapters 1101 and 1150 (relating to general
					 provisions; and MA Program payment policies) and the MA Program Fee
					 Schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › PAYMENT FOR HBP SERVICES › Section 1140.52 - Payment conditions

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will be made to an HBP provider for services
					 furnished if:
(1) The provider has
				  been designated by the Department as a qualified provider.
(2) The services billed to the Department are
				  furnished by the HBP provider or a subcontractor.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › PAYMENT FOR HBP SERVICES › Section 1140.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
HBP payment limitations are as follows:
(1) Payment for the trimester component
				  includes all prenatal visits during the trimester.
(2) Qualified providers may bill for either
				  the high risk maternity care package or the basic maternity care package for
				  each trimester.
(3) The fee for the
				  applicable trimester maternity care packages includes payment to the
				  practitioner for performing the delivery and postpartum care.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › PAYMENT FOR HBP SERVICES › Section 1140.54 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for:
(1) Procedures not listed in the MA Program
				  Fee Schedule.
(2) Services and
				  procedures for which payment is available through other public agencies or
				  private insurance plans as described in §
										1101.64 (relating to third-party
				  medical resources).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › UTILIZATION CONTROL › Section 1140.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
A claim submitted for payment under the MA Program is
					 subject to the utilization review procedures established in Chapter 1101
					 (relating to general provisions). In addition, HBP providers are instructed by
					 the recordkeeping, quality assurance and program evaluation provisions of
					 Section X, "Provider Accountability," of the
HBP Maternity
					 Manual.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1140 - HEALTHY BEGINNINGS PLUS PROGRAM › ADMINISTRATIVE SANCTIONS › Section 1140.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with this part, to have provided services outside the scope of
					 customary standards of medical practice or to have otherwise violated the
					 standards 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 1141 - PHYSICIANS' SERVICES › GENERAL PROVISIONS › Section 1141.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific medically
					 necessary physician's services rendered to eligible recipients by physicians
					 enrolled as providers under the program. Payment for physicians' 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.
The provisions of this §
												1141.1 amended under sections
						403(a) and (b), 443.2(1) and (2), 443.3(1), (2)(i)-(v), 443.4 and 509 of the
						Public Welfare Code (62 P.S. §§
													403(a) and
						(b),
						443.2(1) and (2), 443.3(1),
						443.3(2)(i)-(v), 443.4 and 509).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › SCOPE OF BENEFITS › Section 1141.21 - 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 physicians' services covered by the MA Program subject to the
					 conditions and limitations established in this chapter and Chapter 1101
					 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › SCOPE OF BENEFITS › Section 1141.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for medically
					 necessary physicians' services covered by the MA Program subject to the
					 conditions and limitations established in this chapter and Chapter 1101
					 (relating to the general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › SCOPE OF BENEFITS › Section 1141.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are only eligible for
					 physicians' services provided in the home of the recipient or the office of the
					 physician.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › SCOPE OF BENEFITS › Section 1141.24 - 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 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered services provided by
					 participating physicians subject to the conditions and limitations established
					 in Chapter 1101 (relating to general provisions), §§
										1141.52-1141.57,
					 1141.59 and Chapter 1150 (relating
					 to MA Program payment policies). Payment will not be made for a covered
					 physicians' service if payment is available from another public agency or
					 another insurance or health program.
The provisions of this §
												1141.51 issued under sections
						403(a) and (b), 443.2(1) and (2), 443.3(1) and (2)(i)-(v), 443.4 and 509 of the
						Public Welfare Code (62 P. S. §§
													403(a) and
						(b),
						443.2(1) and (2), 443.3(1),
						443.3(2)(i)-(v), 443.4 and 509).
This section cited in 55 Pa. Code §
												1141.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.52 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
In order for payment to be made to a physician for covered
					 services, such services shall meet the applicable conditions of §§
					 1141.51-1141.57.
This section cited in 55 Pa. Code §
												1141.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.53 - Payment conditions for outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment is made for services performed in
				  an approved Short Procedure Unit (SPU) only if the service could not be
				  appropriately and safely performed in the physician's office, the clinic, or
				  the emergency room of a hospital because of the medical need for inpatient
				  hospital resources such as an operating room and the administration of general
				  anesthesia.
(b) Specialists'
				  examinations and consultations require prior authorization from the Department
				  as described in §
										1101.67 (relating to prior
				  authorization).
(c) Physicians'
				  services provided to recipients in skilled and intermediate care facilities by
				  the physician administrator or medical director of the facility are compensable
				  only if the administrator's or medical director's salary does not include
				  payment for patient care.
(d)
				  Payment for sterilizations is subject to the conditions set forth in §
										1141.55 (relating to payment
				  conditions for sterilizations).
(e)
				  Payment for abortions is subject to the conditions set forth in §
										1141.57 (relating to payment
				  conditions for necessary abortions).
(f) All covered outpatient physicians'
				  services billed to the Department shall be performed by such physician either
				  personally or by a registered nurse, physician's assistant, or a midwife under
				  the physician's direct supervision.
(g) The Department pays a $10 per month fee
				  only to physicians who are approved by the Department to participate in the
				  restricted recipient program as set forth in §
										1101.91 (relating to recipient
				  misutilization and abuse). The physician is paid the $10 monthly fee for the
				  restricted recipient under the physician's medical supervision. This fee is in
				  addition to fees paid to the physician during the month for necessary and
				  covered medical services furnished to restricted recipient.
The provisions of this §
												1141.53 amended under sections
						403(a) and (b), 443.2(1) and (2), 443.3(1) and (2)(i)-(v), 443.4, 443.6 and 509
						of the Public Welfare Code, §§ 403(a) and (b), 443.2(1) and (2),
						443.3(1), 443.3(2)(i)-(v), 443.4, 443.6 and 509 (62 P. S. §§
													403(a) and (b),
						443.2(1) and (2), 443.3(1),
						443.3(2)(i)-(v), 443.4, 443.6 and 509).
This section cited in 55 Pa. Code §
												1141.51 (relating to general
						payment policy); and 55 Pa. Code §
												1141.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.53a - Clinic and emergency room services personal performance-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Consistent
				  with 42 CFR
				  415.152 (relating to definitions), a teaching
				  physician is a physician (other than another resident) who involves residents
				  in the care of that teaching physician's patients.
(b) Clinic services rendered by a resident
				  are compensable when a teaching physician is readily available for immediate
				  face-to-face consultation and assistance.
(c) Emergency room services rendered by a
				  resident are compensable when a teaching physician is readily available for
				  immediate face-to-face consultation and assistance.
(d) Consistent with
				  42 CFR
				  415.180 (relating to teaching setting
				  requirements for the interpretation of diagnostic radiology and other
				  diagnostic tests), the interpretation of diagnostic radiology and other
				  diagnostic tests is compensable. Documentation must indicate that the teaching
				  physician personally performed the interpretation or reviewed the resident's
				  interpretation with the resident.
This section cited in 55 Pa. Code §
												1141.54a (relating to acute care
						hospitals and their short procedure unit services personal
						performance-statement of policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.54 - Payment conditions for inpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A physician is eligible to bill the
				  Department for services he provides to a hospitalized recipient:
(1) If inpatient hospital care is medically
				  necessary as certified by the hospital's utilization review committee or the
				  Department's Bureau of Utilization Review.
(2) For an outpatient (OP) designated
				  procedure, only if the medical condition of the patient is such that to perform
				  the procedure on an outpatient basis could result in undue risk to the life or
				  health of the patient. Detailed documentation supporting the condition of risk
				  to the life or health of the patient shall be included in the patient's medical
				  record and on the claim submitted for payment.
(3) If the hospital has not been denied
				  payment by the Department for the day the service was provided.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.54a - Acute care hospitals and their short procedure unit services personal performance-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Consistent with
				  42 CFR
				  415.152 (relating to definitions), a teaching
				  physician is a physician (other than another resident) who involves residents
				  in the care of that teaching physician's patients.
(b) The Department will reimburse for
				  teaching physician services rendered in acute care hospitals or their short
				  procedure units in accordance with the Medicare standards governing payment for
				  professional services rendered by teaching physicians in
				  42 CFR
				  415.170-415.184, including
				  any subsequent amendments thereto, except as provided in §
										1141.53a (relating to clinic and
				  emergency room services personal performance-statement of policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.55 - Payment conditions for sterilizations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for covered sterilization
				  procedures is made to a physician only if all of the following requirements are
				  met:
(1) The individual requesting
				  sterilization has voluntarily given informed consent in accordance with all
				  requirements described in subsection (b) of this section.
(2) The individual is at least 21 years old
				  at the time informed consent is obtained.
(3) The individual is not a mentally
				  incompetent individual or an institutionalized individual as defined in §
				  1141.2 (relating to definitions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.56 - Payment conditions for hysterectomies

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except as specified in subsection (c), if
				  an individual is not sterile prior to the hysterectomy, payment will be made
				  for a hysterectomy only if all of the following requirements are met:
(1) The hysterectomy was medically necessary
				  and performed for a valid medical reason other than sterilization.
(2) The individual and her representative, if
				  any, were advised orally and in writing, before the operation, that the
				  hysterectomy would render the individual permanently incapable of
				  reproducing.
(3) The individual or
				  her representative, if any, has signed a written acknowledgement of receipt of
				  that information. The acknowledgement statement shall be signed and dated
				  before or after the operation. If the statement is signed after surgery, it
				  must clearly reflect that the individual was informed before the operation. See
				  the Provider Handbook for a facsimile of the Patient Acknowledgement Form for
				  Hysterectomy, MA 30, and for instructions on its
				  completion.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.57 - Payment conditions for necessary abortions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Coverage for abortions funded under the
				  Medical Assistance Program will be available only under the following
				  circumstances:
(1) Where a physician has
				  certified in writing and documented in the patient's record that the life of
				  the woman would be endangered if the pregnancy were allowed to progress to
				  term. The decision as to whether the woman's life is endangered is a medical
				  judgment to be made by the woman's physician.
(i) Payment will be made only if a licensed
				  physician submits a signed "Physician Certification for An Abortion" form, as
				  set forth in Appendix B, with the Medical Services Invoice.
(ii) A second physician's opinion regarding
				  endangerment of the woman's life is optional and is not a prerequisite to
				  payment for a covered abortion. However, the person or the attending physician,
				  with the consent of the person, may obtain a second physician's
				  opinion.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.60 - Payment for medications dispensed or ordered in the course of an office visit

Current through Register Vol. 54, No. 28, July 13, 2024
Physicians may be reimbursed for the actual cost of
					 medications administered or dispensed to an eligible recipient in the course of
					 an office or home visit providing the physician is certified for dispensing by
					 the Office of Medical Assistance, Bureau of Provider Relations. There is no
					 reimbursement to a physician for medical supplies or equipment dispensed in the
					 course of an office or home visit. Payment for medical supplies and equipment
					 is made only to pharmacies and medical suppliers participating in the Medical
					 Assistance program.
Exception:
Physicians may bill the
					 Department for Rho(d) Immune Globulin, intrauterine devices, eyeglasses and for
					 immunizing biologicals and antigens and drugs not provided by the Department of
					 Health.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › UTILIZATION REVIEW › Section 1141.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
All 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 1141 - PHYSICIANS' SERVICES › ADMINISTRATIVE SANCTIONS › Section 1141.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with 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 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 1142 - MIDWIVES' SERVICES › GENERAL PROVISIONS › Section 1142.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific medically
					 necessary midwives' services rendered to eligible recipients by midwives
					 enrolled as providers under the program. Payment for midwives' 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 1142 - MIDWIVES' SERVICES › GENERAL PROVISIONS › Section 1142.2 - 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:
Midwife
-An individual licensed under the
					 laws of this Commonwealth to practice midwifery within the scope of the act of
					 April 4, 1929 (P. L. 160, No. 155) (63 P. S. §§
											171-176).
Midwife services
-A care provided within
					 the scope of a midwife's professional practice and licensure.
This section cited in 55 Pa. Code §
												1151.53 (relating to billing
						requirements).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › SCOPE OF BENEFITS › Section 1142.21 - 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 midwife services compensable under the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › SCOPE OF BENEFITS › Section 1142.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for medically
					 necessary midwife services compensable under the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › SCOPE OF BENEFITS › Section 1142.23 - 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 midwife
					 services unless they are also either categorically or medically needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › SCOPE OF BENEFITS › Section 1142.24 - 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 1142 - MIDWIVES' SERVICES › PROVIDER PARTICIPATION › Section 1142.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
Participation requirements are established in §§
					 1101.41-1101.43 (relating to participation).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › PAYMENT FOR MIDWIVES' SERVICES › Section 1142.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered services provided by
					 participating midwives 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 payment fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › PAYMENT FOR MIDWIVES' SERVICES › Section 1142.52 - Payment conditions

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will be made to a midwife for services furnished
					 if:
(1) The midwife does not have a
				  financial arrangement to provide the services with a hospital, independent
				  medical clinic, rural health clinic or physician.
(2) The services billed to the Department are
				  furnished by the midwife.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › PAYMENT FOR MIDWIVES' SERVICES › Section 1142.54 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for a delivery includes the delivery and at least
					 one outpatient postpartum visit. For an inpatient delivery, payment also
					 includes inpatient care provided during the antepartum and postpartum period.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › PAYMENT FOR MIDWIVES' SERVICES › Section 1142.55 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for:
(1) Procedures not listed in the fee schedule
				  in the MA Program fee schedule.
(2)
				  More than 12 midwife visits per recipient per 365 days (this includes prenatal
				  and postpartum visits). One postpartum visit is included in the delivery fee
				  and is not considered when computing the maximum of 12 visits.
(3) Services and procedures furnished by the
				  midwife for which payment is made to an enrolled physician, rural health
				  clinic, hospital or independent medical clinic.
(4) Services and procedures for which payment
				  is available through other public agencies or private insurance plans as
				  described in §
										1101.64 (relating to third party
				  medical resources (TPR)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1142 - MIDWIVES' SERVICES › UTILIZATION CONTROL › Section 1142.71 - 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 1142 - MIDWIVES' SERVICES › ADMINISTRATIVE SANCTIONS › Section 1142.81 - 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 1143 - PODIATRISTS' SERVICES › GENERAL PROVISIONS › Section 1143.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific medically
					 necessary podiatrists' services rendered to eligible recipients by podiatrists
					 enrolled as providers under the program. Payment for podiatrists' 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 1143 - PODIATRISTS' SERVICES › GENERAL PROVISIONS › Section 1143.2 - 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:
Chronic condition
-An illness which
					 frequently recurs or persists for a period in excess of 3 months.
Compensable service
-A benefit to which a
					 MA recipient is entitled under the MA Program.
Consultation
-A medical evaluation
					 conducted by a specialist at the request of the attending practitioner. For the
					 purposes of the MA Program, a consultation includes taking a medical history,
					 examining the patient, and preparing a written report that is incorporated into
					 the patient's record.
Experimental procedure
-A procedure that
					 deviates from customary standards of medical practice, is not routinely used in
					 the medical or surgical treatment of a specific illness or condition, or is not
					 of proven medical value.
Medical justification
-Written
					 documentation in the patient's medical record indicating the specific health
					 condition or risk that makes the particular service the podiatrist renders,
					 orders or prescribes medically necessary.
Medically necessary
-A term used to
					 describe those medical conditions for which treatment is necessary, as
					 determined by the Department, and which are compensable under the MA
					 Program.
Molded shoes
-Shoes that are constructed
					 from a special last conforming to a specific individual's feet. Molded shoes
					 are constructed from leather or other durable material.
Noncompensable service
-A service a
					 provider furnishes for which there is no provision for payment under this
					 chapter.
Nonemergency medical services
-A
					 compensable podiatrists' service provided for conditions not requiring
					 immediate medical intervention in order to sustain the life of the person or to
					 prevent damage to health.
Orthopedic shoes
-Shoes that have a
					 Goodyear welt, steel shank and elongated medial counter which are modified to
					 compensate for an abnormality of the feet.
Shoe insert
-A device that is constructed
					 of plexiglass, hard plastic or other rigid material fashioned for the
					 individual feet by a laboratory approved to participate in the MA Program, and
					 is fabricated according to a podiatrist's prescription.
This section cited in 55 Pa. Code §
												1143.58 (relating to
						noncompensable services and items).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › SCOPE OF BENEFITS › Section 1143.21 - 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 podiatrists' services compensable under the MA Program, subject to
					 the conditions and limitations established in this chapter and Chapter 1101
					 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › SCOPE OF BENEFITS › Section 1143.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for podiatrists'
					 services compensable under the MA Program, subject to the conditions and
					 limitations established in this chapter and Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › SCOPE OF BENEFITS › Section 1143.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
Individuals who receive a State Blind Pension are not
					 eligible for podiatrists' services under the MA Program, unless the individuals
					 are determined to be either categorically or medically needy, in which case
					 they are eligible for podiatrists' services compensable under the MA
					 Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › SCOPE OF BENEFITS › Section 1143.24 - 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 1143 - PODIATRISTS' SERVICES › PROVIDER PARTICIPATION › Section 1143.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
Participation requirements are established in §§
					 1101.41-1101.43 (relating to participation).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › PAYMENT FOR PODIATRISTS' SERVICES › Section 1143.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for compensable services provided by
					 participating podiatrists subject to the conditions and limitations established
					 in §§
										1143.52-1143.58 and Chapters 1101 and 1150
					 (relating to general provisions; and MA Program payment policies) and the MA
					 Program fee schedule. Payment will not be made for a compensable podiatrist's
					 service if full payment as specified in §
										1101.62 (relating to maximum fees)
					 is available from another public agency or another insurance or health
					 program.
This section cited in 55 Pa. Code §
												1143.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › PAYMENT FOR PODIATRISTS' SERVICES › Section 1143.52 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
In order for payment to be made to a podiatrist for
					 compensable services, the services shall meet the applicable conditions of
					 §§ 1143.51-1143.57.
This section cited in 55 Pa. Code §
												1143.51 (relating to general
						payment policy).