Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › GENERAL PROVISIONS › Section 1221.2 - 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:
Abortion
-The deliberate termination of a
					 pregnancy.
Acute illness
-A brief illness marked by
					 the sudden onset of severe symptoms.
Clinic
-A hospital clinic, medical school
					 clinic, or independent clinic that provides preventative, diagnostic,
					 therapeutic, rehabilitative or palliative services on an outpatient basis. The
					 clinic is distinct from a group practice in that it has a director, an
					 organized structure, a written program designed to implement the objectives of
					 the clinic, and a professional and administrative quality review program that
					 evaluates the effectiveness of the outpatient service in relation to the stated
					 objectives.
Contract physician
-A physician who is paid
					 for professional services by salary or other arrangement such as hourly wage or
					 per diem, by an employer such as a hospital, clinic, or governmental agency. An
					 individual physician may be both an independent and contract physician. The
					 fact that a physician is under contract does not preclude the physician from
					 providing services on a fee for service basis to the private patients of the
					 physician.
Emergency accident care
-The initial
					 examination and treatment performed in connection with and within 72 hours
					 following an injury. Examples of emergency accident care include but is not
					 limited to the following: removal of foreign body in the eye, treatment of
					 abrasions, contusions, acute sprains or strains, nose bleeds-caused by trauma,
					 insect bites or stings, choking on food, drink, or foreign body, resuscitation
					 of drowning or smoke inhalation victims, or treatment of concussion, or
					 poisoning-chemical or drug.
Emergency medical care
-edical care
					 rendered in response to the sudden onset of a medical condition requiring
					 medical, not surgical, intervention to sustain the life of the person or to
					 prevent damage to the person's health and which the recipient secures
					 immediately after the onset, or as soon thereafter as the care can be made
					 available, but in no case later than 72 hours after the onset. In order to
					 determine whether a medical emergency existed and, therefore, whether benefits
					 for outpatient services in connection with the treatment of the condition are
					 payable on an emergency basis, the following criteria shall be applied:
(i)
Severe symptoms have to
				  occur
-The symptoms must be sufficiently severe to cause a person to
				  seek immediate medical aid. Some symptoms or conditions indicating medical
				  emergency care are listed in Appendix A.
(ii)
Severe symptoms must occur
				  suddenly and unexpectedly
-Subacute symptoms of a chronic condition
				  would not qualify as a medical emergency. However, chronic symptoms that
				  suddenly become severe enough to require immediate intervention would qualify.
Hospital emergency room
-An entity within a
					 hospital, organizationally distinct from other outpatient facilities, the
					 primary function of which is to provide emergency accident and emergency
					 medical or surgical care.
Hospital outpatient clinic
-A hospital
					 operated facility that provides primary nonemergency health care on an
					 outpatient basis. The hospital may contract out this function but the hospital
					 shall be recognized as the provider.
Hospital outpatient department
-An
					 organizational division of a hospital composed of hospital outpatient clinics
					 designed to provide comprehensive or specialized medical care on an outpatient
					 basis. For the purpose of reimbursement under this chapter, a hospital
					 outpatient department shall not include the hospital emergency room, outpatient
					 psychiatric clinic, or outpatient drug and alcohol clinic when the hospital
					 operates such facilities directly or through contract agreements. Reimbursement
					 for outpatient psychiatric services are subject to Chapter 1153 (relating to
					 outpatient psychiatric services). Reimbursement for outpatient drug and alcohol
					 services are subject to Chapter 1223 (relating to outpatient drug and alcohol
					 clinic services).
Independent medical clinic
-A free-standing
					 facility which provides comprehensive primary health care and which is neither
					 located in a hospital owned nor under the management and control of the
					 hospital. An independent medical clinic shall be operated by a public or
					 private nonprofit corporation other than a hospital or corporation that owns or
					 operates a hospital.
Independent physician
-A physician who is
					 paid for professional services on a fee-for-service basis. The physician may be
					 in private practice alone or in a group with other physicians. An independent
					 physician or group may be incorporated.
Institutionalized individual
-A person who
					 is one of the following:
(i)
				  involuntarily detained under a civil or criminal statute in a correctional,
				  rehabilitative or mental retardation facility including a psychiatric hospital
				  or other facility for the care and treatment of mental illness or mental
				  retardation.
(ii) confined under
				  voluntary commitment in a psychiatric hospital, mental retardation facility or
				  other facility for the care and treatment of mental illness or mental
				  retardation.
Medical school clinic
-A primary health
					 care facility operated by a medical college located in the Commonwealth of
					 Pennsylvania which has been fully accredited by the Association of American
					 Medical Colleges or the American Medical Association and which has an agreement
					 with a hospital to serve as its outpatient department.
Medical school outpatient department
-A
					 term used to describe collectively all medical school clinics operated by a
					 medical college. For the purpose of reimbursement under this chapter, a medical
					 school outpatient department shall not include the outpatient psychiatric
					 clinic or outpatient drug and alcohol clinic regardless of whether the medical
					 school operates such facilities directly or through contract agreements.
					 Reimbursement for outpatient psychiatric services are subject to Chapter 1153.
					 Reimbursement for outpatient drug and alcohol services are subject to Chapter
					 1223.
Mentally incompetent individual
-A person
					 who has been declared mentally incompetent by a Federal, State or local court
					 of competent jurisdiction for any purpose unless he has been declared competent
					 for the purposes which include the ability to consent to sterilization.
Noncompensable item
-A service a provider
					 furnishes for which there is no provision for payment under MA
					 regulations.
Nonemergency medical services
-A
					 compensable physicians' services provided for conditions not requiring
					 immediate medical intervention in order to sustain the life of the person or to
					 prevent damage to his health.
Nonprofit
-A term which describes a private
					 agency, institution or organization which is a corporation or association, or
					 is owned or operated by one or more corporations or associations, no part of
					 the net earnings of which inures, or may lawfully inure to the benefit of a
					 private shareholder or individual.
Physician
-An individual licensed under the
					 laws of the Commonwealth to practice medicine and surgery within the scope of
					 the Medical Practice Act 1974 (63 P. S. §
											421.11) or the Osteopathic Medical Practice
					 Act (63 P. S. §§
											271.1-271.18).
Primary health care
-Preventive,
					 diagnostic, therapeutic, rehabilitative or palliative services provided by or
					 under the supervision of a physician.
Rural health clinic
-A clinic that is
					 located in a rural area designated by the Department of Health and Human
					 Services as a shortage area with respect to primary health care. Rural health
					 clinics so designated participate in the Medical Assistance program subject to
					 the regulations set forth in Chapter 1229 (relating to health maintenance
					 organization services).
Support services
-The basic facilities,
					 supplies and ancillary services necessary to deliver health care on an
					 outpatient basis.
Surgical services
-Those procedures listed
					 in the Medical Assistance program fee schedule.
Visit
-A face-to-face encounter between a
					 patient and a member of the independent clinic, hospital outpatient department
					 or hospital emergency room staff for the purpose of receiving medical services
					 provided by or under the direction of a physician. Encounters with more than
					 one health professional and multiple encounters with the same health
					 professional which take place on the same day constitute a single
					 visit.
This section cited in 55 Pa. Code §
												1221.55 (relating to payment
						conditions for sterilizations).