Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › COVERED AND NONCOVERED SERVICES › Section 1223.14 - Noncovered services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for the following types of
					 services regardless of where or to whom they are provided:
(1) Nonmedical counseling consisting of
				  supportive activities to improve an individual's problem-solving and coping
				  skills and intrapersonal or interpersonal development and functioning; and
				  group recreation or group social activities, as group psychotherapy.
(2) Clinic visits, psychotherapy, diagnostic
				  psychological evaluations, psychiatric evaluations and comprehensive medical
				  evaluations conducted over the telephone, that is, any clinic service conducted
				  over the telephone.
(3) Cancelled
				  appointments.
(4) Covered services
				  that have not been rendered.
(5)
				  Inpatient hospital methadone maintenance.
(6) Vocational rehabilitation; day care;
				  drug/alcohol or mental health partial hospitalization; reentry programs,
				  occupational or recreational therapy; Driving While Intoxicated (DWI) or
				  Driving Under the Influence Programs or Schools; referral, information or
				  education services; experimental services; training; administration; follow-up
				  or aftercare; program evaluation; case management; central intake or records;
				  shelter services; research; drop-in, hot-line or social services; inpatient
				  nonhospital or occupational program services, or any other service or program
				  not specifically identified as a covered service in Chapter 1150 (relating to
				  Medical Assistance Program payment policies) and the Medical Assistance (MA)
				  Program fee schedule.
(7) An MA
				  covered service, including drug/alcohol clinic services, provided to inmates of
				  State or county correctional institutions or committed residents of public
				  institutions.
(8) Drug/alcohol
				  outpatient clinic services provided to residents of treatment institutions,
				  that is, persons who are also being provided with room and board and services
				  on a 24-hour basis by the same facility or distinct part of the facility or
				  program. Drug/alcohol outpatient clinic services provided to residents of
				  inpatient nonhospital and shelter facilities.
(9) Drug/alcohol outpatient clinic services
				  provided to patients receiving psychiatric partial hospitalization services
				  under the MA Program or drug/alcohol partial hospitalization services under the
				  Department of Health.
(10) Covered
				  drug/alcohol clinic services, with the exception of family psychotherapy,
				  provided to persons without a drug/alcohol abuse or dependence diagnosis who
				  are family members, other relatives, friends, acquaintances or live-in
				  companions of the eligible recipient with a drug/alcohol abuse or dependence
				  problem solely because of a relationship to the recipient. Payment will be made
				  only for covered services directly provided to eligible MA recipients who have
				  been diagnosed by a licensed physician as having a drug/alcohol abuse or
				  dependence problem.
(11) Services
				  delivered at locations other than approved drug/alcohol outpatient clinics with
				  the exception of home visits under the conditions specified in §
										1223.52(d)
				  (relating to payment conditions for various services).
(12) Methadone maintenance clinic visits on
				  days when the patient has take-home privileges, that is, self-administers
				  methadone at home.
(13) Home visits
				  not provided in accordance with the conditions specified in §
				  1223.52(d).
(14) Methadone
				  maintenance clinic services provided before the date of the physician's
				  comprehensive medical examination, diagnosis and treatment plan.
(15) Services provided without a level of
				  care assessment for each patient prior to admission to the clinic.
(16) Services provided within or beyond the
				  15th calendar day following intake, without the clinic's supervisory
				  physician's review and approval of the patient's level of care assessment,
				  psychosocial evaluation, treatment plan and determination of the patient's
				  diagnosis as specified in §
										1223.52(a)(6)(i).
The provisions of this §
												1223.14 amended under section
						443.3(1) of the
						Public Welfare Code (62 P. S. §
													443.3(1)).
This section cited in 55 Pa. Code §
												1223.54 (relating to
						noncompensable services and items).