reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › PROVIDER PARTICIPATION › Section 1149.43a - Clarification of the terms "in writing", "written" and "signature"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The terms
				  "in writing" and "written" in §
										1149.43(7) and
				  (8) (relating to requirements for dental
				  records) include prescriptions that are handwritten or transmitted by
				  electronic means.
(b) Written
				  prescriptions transmitted by electronic means must be electronically encrypted
				  or transmitted by other technological means designed to protect and prevent
				  access, alteration, manipulation or use by any unauthorized person.
(c) The term "signature" in §
										1149.43(8)(vi)
				  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 1149 - DENTISTS' SERVICES › PAYMENT FOR DENTISTS' SERVICES › Section 1149.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for dentists' services is 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. The following payment policies are applicable for dental
					 services:
(1) The amount paid for
				  dental services is the dentist's usual charge to the general public or the fees
				  listed in MA Program fee schedule, whichever is less.
(2) Payment is made for the services or items
				  listed in the amounts specified in the MA Program fee schedule on behalf of a
				  person no longer eligible for MA, provided the person was an eligible MA
				  recipient at the time the ser-vice was initiated and the invoice for payment is
				  submitted within 180 days after the service was initiated.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › PAYMENT FOR DENTISTS' SERVICES › Section 1149.52 - Payment conditions for various dental services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The fee paid by the Department for an
				  inpatient surgical service includes pre-operative and postoperative visits as
				  designated in the MA Program fee schedule.
(b) The Department pays only one dentist for
				  performing a particular surgical service or procedure.
(c) Payment is made at reduced rates for
				  space maintainers, crowns and dentures specified in MA Program fee schedule, if
				  one of the following conditions are met:
(1)
				  The person was an eligible MA recipient at the first visit after prior
				  authorization was obtained as specified in subsection (j) but became ineligible
				  for MA before the appliance was delivered.
(2) The dentist was unable to deliver the
				  item to the recipient, and the following conditions were met:
(i) When the appliance is completed, the
				  dentist shall notify the recipient and make an appointment. If the dentist is
				  unable to contact the patient after 30 days, in spite of repeated attempts
				  which must be documented in the recipient's dental record, the dentist shall
				  also send a letter to the recipient's last known address and to the Executive
				  Director of the appropriate County Assistance Office.
(ii) If neither the dentist nor the County
				  Assistance Office can locate the recipient within the 60 days after the
				  appliance is completed, the dentist shall submit an invoice for the service
				  performed in accordance with the instructions in the provider
				  handbook.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › PAYMENT FOR DENTISTS' SERVICES › Section 1149.54 - Payment policies for orthodontic services

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the payment policies established in this
					 chapter, Chapters 1101 and 1150 (relating to the general provisions; and MA
					 Program payment policies) and the MA Program fee schedule the following payment
					 policies apply to orthodontic services:
(1) Payment for orthodontic services is made
				  only if all of the conditions specified in §
										1149.55 (relating to payment
				  conditions for orthodontic services) are met.
(2) Payment for orthodontic services is
				  subject to the limitations set forth in §
										1149.56 (relating to payment
				  limitations for orthodontic services).
(3) Payment is made only for those quarters
				  during which the recipient is seen by the orthodontist and treatment is
				  rendered.
(4) Payment for covered
				  and approved orthodontic service is made on a quarterly basis as set forth in
				  the MA Program fee schedule. The first quarter begins on the recipient's first
				  appointment day after the Department has authorized payment for the orthodontic
				  services.
(5) The fees listed in
				  the MA Program fee schedule include all appliances furnished by the
				  orthodontist during the course of the orthodontic treatment.
(6) The fees listed in the MA Program fee
				  schedule for the first quarter of treatment includes the cost of diagnostic
				  aids such as models, photographs, radiographs and the like except as noted in
				  paragraph (7).
(7) Payment for
				  diagnostic aids is made only if the Department requests the diagnostic aids for
				  review before the decision is made to approve orthodontic treatment and the
				  treatment is denied by the Department.
(8) Payment will be discontinued for persons
				  who become ineligible for MA benefits during the course of the orthodontic
				  treatment. The last payment will be for the quarter in which the recipient
				  becomes ineligible.
(9) Payment is
				  made for orthodontic services for persons receiving orthodontic treatment at
				  the time their eligibility for MA benefits begins in accordance with the
				  policies set forth in this chapter subject to the conditions set forth in
				  §§ 1149.55 and 1149.56.
(10) Payment will not be made for recipients
				  beginning orthodontic treatment through the Department of Health's Cleft Palate
				  Program, Division of Rehabilitation.
This section cited in 55 Pa. Code §
												1149.56 (relating to payment
						limitations for orthodontic
						services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › PAYMENT FOR DENTISTS' SERVICES › Section 1149.55 - Payment conditions for orthodontic services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for orthodontic services is subject to the
					 following conditions and requirements:
(1) The Department has authorized for the
				  services prior to provision of the services as referenced in §
										1149.52(j)(3)
				  (relating to payment conditions for various dental services).
(2) The orthodontist is Board eligible or
				  Board certified as defined in §
										1149.2 (relating to
				  definitions).
(3) They are
				  necessary to prevent irreversible damage to the teeth or their supporting
				  structures.
(4) They are necessary
				  to treat acute dental problems as evidenced by the following factors:
(i) Dentofacial abnormalities that severely
				  compromise the client's physical health, as manifested by markedly protruding
				  upper jaw and teeth, protruding lower jaw and teeth, the protrusion of upper
				  and lower teeth so that the lips cannot be brought together, under-developed
				  lower jaw and receding chin or marked asymmetry of the lower face.
(ii) Obvious difficulty in eating because of
				  the malocclusion, so as to require liquid or semisoft diet, or cause pain in
				  jaw joints during eating, or extreme grimacing or excessive motions of the
				  orofacial muscles during eating because of necessary compensation for anatomic
				  deviations.
(iii) Obvious severe
				  breathing difficulties related to the malocclusion, such as unusually long
				  lower face with downward rotation of the mandible and with lips that cannot be
				  brought together, chronic mouth breathing and postural abnormalities relating
				  to breathing difficulties-for example, head forward and extended, round
				  shouldered.
(iv) Lisping or other
				  speech articulation errors that are directly related to orofacial
				  abnormalities.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › PAYMENT FOR DENTISTS' SERVICES › Section 1149.56 - Payment limitations for orthodontic services

Current through Register Vol. 54, No. 28, July 13, 2024
The following limits apply to payment for orthodontic
					 services:
(1) Payment is made for only
				  one Salzmann Index Evaluation per 12 month period per recipient.
(2) Payment for diagnostic aids requested by
				  the Department under §
										1149.54(7)
				  (relating to payment policies for orthodontic services) will not exceed the fee
				  for diagnostic aids which is listed under orthodontic exam in the MA Program
				  fee schedule.
(3) Payment will not
				  be made for quarters of orthodontia treatment initiated before March 1,
				  1980.
(4) Payment is made for only
				  8 quarters of treatment per lifetime except as noted in paragraph
				  (5).
(5) For those persons who
				  began orthodontic treatment prior to becoming eligible for MA, payment is made
				  only for the difference between 8 quarters of care and quarters of care
				  received prior to the person's eligibility for MA.
(6) Payment for orthodontic services will not
				  exceed $1,075. The fees paid for the initial orthodontic exam and treatment
				  including the Salzmann Evaluation Index and the fees paid for the first quarter
				  through the eighth quarter are listed in the Medical Assistance program fee
				  schedule.
(7) Payment of the fee
				  for each quarter as listed in the MA Program fee schedule is limited to one in
				  each recipient's lifetime.
(8) The
				  amount of payment for each quarter of care is limited to the fee listed in the
				  MA Program fee schedule.
This section cited in 55 Pa. Code §
												1149.54 (relating to payment
						policies for orthodontic services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › PAYMENT FOR DENTISTS' SERVICES › Section 1149.57 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
No payment will be made to a dentist for the following
					 services or items:
(1) Services or
				  items not listed in the MA Program fee schedule.
(2) Silicate, acrylic or plastic restorations
				  involving the occlusal surfaces of posterior teeth.
(3) Dental services for cosmetic
				  purposes.
(4) Anesthesia services
				  performed in a hospital short procedure unit, hospital emergency room or on an
				  inpatient hospital basis.
(5)
				  Diagnostic or pathological examinations of body fluids or tissues. Payment for
				  these procedures is made only to hospital and independent laboratories approved
				  for participation in the MA Program.
(6) Radiographs improperly identified as
				  specified in §
										1149.43(5) and
				  (6) (relating to requirements for dental
				  records) or not clearly readable or free from defects.
(7) Troches, lozenges, throat tablets, cough
				  drops, chewing gum, mouth washes, and the like, prescribed for local treatment
				  of disorders of the mouth and throat, even though the products are combined
				  with antibiotic, antibacterial, analgesic, anesthetic or antitussive
				  agents.
(8) Medications and
				  supplies furnished by a dentist during the course of an examination or
				  treatment.
(9) Initial oral
				  examination or periodic oral examination when emergency treatment is
				  provided.
(10) Fluoride treatment
				  for persons 17 years of age or older.
(11) Self-curing dental materials.
(12) Crowns which are splinted for
				  periodontal reasons.
(13) Crowns in
				  conjunction with a bridge.
(14)
				  Pontics in conjunction with a bridge.
(15) Fixed bridgework.
(16) Pulpotomy on fully developed permanent
				  teeth.
(17) Root canal treatment,
				  other than paste filling material, on primary teeth.
(18) Dental services other than those
				  specified in §
										1149.21 (relating to scope of
				  benefits for the categorically needy), unless provided to MA recipients under
				  21 years of age.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › UTILIZATION › Section 1149.71 - 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 1149 - DENTISTS' SERVICES › ADMINISTRATIVE SANCTIONS › Section 1149.81 - 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 dental 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 1150 - MA PROGRAM PAYMENT POLICIES › GENERAL PROVISIONS › Section 1150.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payments for specific medically
					 necessary medical services and items covered by the Program and furnished to
					 eligible recipients by approved providers enrolled in the Program. Payment for
					 these services and items is subject to the provisions and limitations of this
					 chapter, Chapter 1101 (relating to general provisions), and the specific
					 chapters for each provider type. To the extent that this chapter conflicts with
					 the regulations that relate to reimbursement for various services or items
					 contained in the specific MA provider chapters in effect on January 1, 1983,
					 this chapter will control. To the extent that this chapter does not address a
					 reimbursement question answered by a regulation contained in a specific
					 provider chapter, the regulation in the specific provider chapter controls.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.52 - Anesthesia services

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment will be made for anesthesia services other than local anesthesia
				  provided by an enrolled practitioner qualified to administer anesthesia only if
				  either of the following conditions are met:
(1) The practitioner personally administered
				  the anesthesia.
(2) The
				  practitioner directed no more than four anesthesia procedures concurrently and
				  did not perform other services while concurrently directing the procedures. If
				  the physician is involved in more than four anesthesia procedures concurrently,
				  they should be deemed supervision and the costs shall be included as part of
				  the hospital's costs.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.54 - Surgical services

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Inpatient surgical services.
(1) A practitioner may bill for any covered
				  surgical procedure performed on an inpatient basis unless the surgical
				  procedure could appropriately and safely be performed on an outpatient basis in
				  an office, clinic, emergency room or in a hospital short procedure
				  unit.
(2) Those surgical procedures
				  designated in the Medical Assistance Program Fee Schedule with an outpatient
				  indicator (OP) are not compensable when performed on an inpatient basis unless
				  the medical condition of the patient is such that to perform the procedure on
				  an outpatient basis, including a short procedure unit, could result in undue
				  risk to the life or health of the patient. Detailed documentation of 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) An assistant surgeon may bill only for
				  the surgical procedures designated in the Medical Assistance Program Fee
				  Schedule with the assistant surgeon indicator. The maximum payment to the
				  assistant surgeon will be an amount equal to 20% of the Medical Assistance
				  maximum allowable payment made to the surgeon. See paragraph (4).
(4) The fee for an inpatient surgical
				  procedure includes:
(i) Preoperative inpatient
				  visits.
(ii) Inpatient and
				  outpatient office or home visits provided by the practitioner who performed the
				  procedure for a purpose related to surgery or surgical diagnosis during the
				  number of postoperative days specified in the Medical Assistance Program Fee
				  Schedule for each surgical procedure. During this specified period, the
				  practitioner who performed the surgery is eligible to receive payment for
				  treatment of a medical or surgical condition if the diagnosis necessitating the
				  treatment is different and unrelated to the surgery.
(iii) The removal of sutures and
				  casts.
(5) When two or
				  more surgical procedures are performed by the same practitioner during the same
				  period of hospitalization, the practitioner will be reimbursed at 100% for the
				  highest allowable payment for one procedure and 25% for the second highest
				  paying procedure, with no payment for additional procedures.
(6) A practitioner who performs a surgical
				  procedure may also bill for medical diagnostic procedures, surgical diagnostic
				  procedures, and radiation therapy for the same patient during the same period
				  of hospitalization.
(7) Payment may
				  be made to a practitioner who performs the surgical procedure and to one other
				  practitioner who is responsible for the medical care of the same
				  patient.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.55 - Obstetrical services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  fee for a delivery includes:
(1) Antepartum
				  care provided on an inpatient basis.
(2) Inpatient and outpatient office or home
				  visits provided by the practitioner who performed the delivery, for a purpose
				  related to delivery, during the number of postpartum days specified in the
				  Medical Assistance Program Fee Schedule for each obstetrical procedure. During
				  this specified period, the practitioner who performed the delivery is eligible
				  to receive payment for treatment of a medical or surgical condition if the
				  diagnosis necessitating the treatment is different and unrelated to the
				  delivery.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.56 - Medical services

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Inpatient medical care.
(1)
				  On any given day, a pracitioner may bill for only one of the following:
(i) An initial comprehensive visit.
(ii) An initial limited visit.
(iii) Prolonged medical attention.
(iv) A consultation.
(v) A surgical procedure.
(vi) An inpatient hospital visit.
(vii) An Early and Periodic Screening,
				  Diagnosis, and Treatment visit.
(viii) Stand-by services for high risk
				  deliveries or Cesarean sections.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.56a - Payment policy for consultations-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department pays for five levels of
				  inpatient and outpatient consultations. Payment for inpatient consultations is
				  limited to two consultations per hospitalization. The definition of each level
				  is set forth in subsection (b).
(1) A referral
				  to another practitioner does not constitute a consultation. When a patient is
				  referred to another practitioner, the medical record shall indicate the name of
				  the practitioner and the reason for the referral. When a physician transfers
				  the total responsibility for care of the patient to another practitioner, the
				  physician accepting the patient may bill for medical care or surgical
				  procedures. This transfer of responsibility shall be noted in the patient's
				  medical record.
(2) Payment will
				  not be made for a self-referred consultation. A consultation shall be requested
				  by another practitioner.
(3)
				  Payment will not be made for a consultation when it is performed by a surgeon
				  or assistant surgeon regarding the advisability of definitive surgery and
				  surgery is subsequently performed by that surgeon or assistant surgeon. This is
				  not applicable to second opinions mandated by the Department's Second Opinion
				  Program.
(4) Payment will be made
				  for a consultation provided by a surgeon regarding the advisability of
				  definitive surgery when subsequent surgery is not performed.
(5) Payment will not be made for a
				  consultation when it is performed by the same physician or assistant who
				  performs the obstetrical delivery.
(6) Payment will not be made for a
				  consultation provided by an anesthesiologist prior to surgery. This is
				  considered to be a pre-operative work-up and the fee for anesthesia services
				  includes payment for the pre-operative work-up.
(7) Payment will be made for a consultation
				  provided by an anesthesiologist if the consultation results in a decision not
				  to administer anesthesia during the hospitalization.
(8) Payment for an inpatient consultation
				  includes follow-up care; therefore, the consultant is not eligible to bill for
				  daily medical care. Only the attending physician is entitled to bill for daily
				  medical care.
(9) Payment will not
				  be made for consultations which are performed solely to meet a hospital
				  requirement.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.56b - Payment policy for observation services - statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
				  will pay for clinically-appropriate and medically necessary observation
				  services while a decision is made as to whether an MA beneficiary requires
				  admission for inpatient acute care services or may be discharged to a
				  nonhospital setting.
(b)
				  Clinically-appropriate and medically necessary observation services include
				  short-term treatment, assessment and reassessment that are furnished in the
				  acute care general hospital outpatient setting.
(c) Observation services shall be prescribed
				  or ordered prior to the acute care general hospital or practitioner rendering
				  the service.
(d) The Department
				  will pay acute care hospitals a one-time support component fee for observation
				  services for a period of observation. The support component fee includes
				  payment for all ancillary and diagnostic services provided during the period of
				  observation.
(e) An acute care
				  general hospital shall provide a minimum of 8 hours of observation services to
				  be paid the support component fee.
(f) The Department will pay physicians,
				  dentists and podiatrists a visit fee for observation services. The Department
				  will pay physicians, dentists and podiatrists a separate professional component
				  fee for ancillary and diagnostic services provided during the period of
				  observation.
(g) Payments to
				  physicians, dentists and podiatrists are subject to the conditions and
				  limitations established in Chapters 1141, 1143, 1149 and 1150.
(h) The Department will not make payment for
				  observation services in conjunction with the following:
(1) Short procedure unit surgical procedures,
				  including surgical recovery time.
(2) Inpatient acute care general hospital
				  services.
(3) Emergency room
				  services.
(4) Hospital clinic
				  services.
(5) Hospital physical
				  therapy, occupational therapy and speech therapy services provided on any day
				  other than the first calendar day of the period of observation.
(6) Special treatment room
				  services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.57 - Diagnostic services and radiation therapy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The fees for diagnostic radiology,
				  nuclear medicine, radiation therapy, pathology and medical diagnostic
				  procedures are comprised of a total fee, which is divided into a professional
				  component fee and a technical component fee.
(b) The technical component of any diagnostic
				  services provided on an inpatient basis will be included in the hospitals'
				  payment for inpatient services. No other payment will be made for the total
				  component or technical component for inpatient services.
(c) Physicians may bill for a visit in
				  addition to the professional component if an appropriate medical care visit is
				  provided. However, a visit to a practitioner's office or the outpatient
				  department of a hospital solely for the purpose of receiving a diagnostic
				  service or radiation therapy does not qualify for payment for a visit and the
				  diagnostic service or radiation therapy. In this kind of situation, payment is
				  made only for the diagnostic service or radiation therapy.
(d) A practitioner may bill for laboratory
				  services performed in the office only if the practitioner is licensed by the
				  Department of Health and enrolled in the MA Program as a laboratory.
(e) A practitioner may bill for medical
				  diagnostic, surgical diagnostic, diagnostic radiology, nuclear medicine and
				  radiation therapy in addition to:
(1) A
				  surgical procedure.
(2) A medical
				  care visit if the situation described in subsection (c) does not
				  occur.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.58 - Prior authorization

Current through Register Vol. 54, No. 28, July 13, 2024
Prior authorization is required for those services and
					 items so designated in the MA Program fee schedule with the prior authorization
					 indicator (PA).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.59 - PSR program

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except
				  as specified in subsection (b), a practitioner or facility shall request a PSR
				  prior to the admission of a MA recipient to a general hospital, freestanding
				  ambulatory surgical center or hospital short procedure unit for surgical or
				  medical treatment.
(b) For the
				  following type of admission, a practitioner is not required to request a PSR:
(1) An emergency admission as defined in
				  §
											1150.2 (relating to
				  definitions).
(2) An urgent
				  admission as defined in § 1150.2.
(3) A maternity admission as defined in
				  § 1150.2.
(4) A newborn
				  admission as defined in § 1150.2.
(5) The admission of a MA recipient who is
				  also eligible for Medicare Part A benefits and for which the Department is
				  responsible only for the deductible or coinsurance payment amounts.
(6) A recipient who is enrolled in a
				  comprehensive health services plan or a capitated physician case management
				  program.
(7) The admission of a MA
				  recipient to a hospital based psychiatric unit, medical rehabilitation unit,
				  drug and alcohol treatment/rehabilitation unit, freestanding rehabilitation
				  hospital or freestanding drug and alcohol rehabilitation hospital as identified
				  under Chapter 1163 (relating to inpatient hospital services) or to a
				  freestanding psychiatric hospital as identified under Chapter 1151 (relating to
				  private psychiatric hospital inpatient services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.60 - Second opinion program

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except
				  as specified in subsection (g), a practitioner is required to refer a recipient
				  to the Department to arrange an appointment for a second opinion when the
				  proposed procedure is one that automatically requires a second
				  opinion.
(b) The Department may
				  require a recipient to obtain a second opinion if the Department's physicians
				  question the medical necessity of performing the procedure through the PSR
				  program under § 1150.59 (relating to PSR program).
(c) The Department will provide the recipient
				  with the names of practitioners within the recipient's vicinity who are
				  approved to provide a second opinion. The Department will arrange an
				  appointment with the practitioner the recipient chooses. The arrangement for
				  the appointment will be completed no later than 6 working days after the
				  request by the recipient or the recipient's agent.
(d) After the recipient obtains a second
				  opinion, the final decision on whether or not to have the procedure performed
				  will be made by the recipient, even if the second opinion is contrary to the
				  opinion of the attending practitioner. If the recipient decides to undergo the
				  procedure, the Department will make payment in accordance with the Department's
				  applicable payment regulations.
(e)
				  If the recipient fails to obtain a second opinion required in subsection (a) or
				  (b), the Department will not precertify the admission.
(f) A second opinion is not required if one
				  of the following conditions applies:
(1) The
				  procedure is documented in the recipient's medical record as an emergency or
				  urgent admission by the attending practitioner and that immediate or prompt
				  surgery is medically indicated.
(2)
				  The patient is enrolled in a comprehensive health services plan or a capitated
				  physician case management program.
(3) The patient is also covered by another
				  health insurance and has obtained a second opinion under that program for the
				  procedure for which MA coverage is sought.
(4) Another health insurance is expected to
				  make payment for the service and MA is not expected to make an additional
				  payment.
(5) The patient was not
				  eligible for MA at the time the procedure was performed but subsequently became
				  eligible.
(6) The Department has
				  approved the admission of a recipient to a hospital and during the hospital
				  stay it is determined that the recipient needs a surgical procedure that would
				  otherwise require a second opinion under subsection (a) or (b).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.60a - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
This section cited in 55 Pa. Code §
												1150.60 (relating to second
						opinion program).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.61 - Guidelines for fee schedule changes

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Notice will be published in the
Pennsylvania Bulletin
when fees are changed and when
				  procedures, services or items are added to, or deleted from, the MA Program Fee
				  Schedule.
(b) Procedures, services
				  and items requested by providers, the MA Advisory Committee, the Senate Public
				  Health and Welfare Committee, and the House Health and Welfare Committee, the
				  Department or other interested parties may be added to the MA Program Fee
				  Schedule on the basis of the following:
(1)
				  The procedure, service or item is determined to be medically necessary by the
				  Department after consultation with the MA Advisory Committee, other third-party
				  payors and the Department's medical consultants.
(2) The procedure, service or item is
				  accepted as a standard practice by the medical community.
(3) The procedure, service or item is not
				  prohibited by Federal or State statute or regulation.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.62 - Payment levels and notice of rate setting changes

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will establish maximum
				  payment rates for MA covered services. The established maximum payment rates
				  will not exceed the Medicare upper limit.
(b) The Department will issue public notice
				  of changes in Statewide methods and standards for setting payment rates as
				  required by Federal law.
The provisions of this §
												1150.62 amended under sections
						201(2), 403(b), 443.4 and 454 of the Public Welfare Code (62 P. S. §§
													201(2),
						403(b), 443.4 and
						454).
This section cited in 55 Pa. Code §
												1126.52 (relating to payment
						criteria); and 55 Pa. Code §
												5221.42 (relating to
						payment).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.63 - Waivers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
				  may waive the requirements of §
										1150.51(6)
				  (relating to general payment policies) upon written request by a
				  provider.
(b) The Department, under
				  extraordinary circumstances, will pay for a medical service or item that is not
				  one for which the MA Program has an established fee. If a practitioner
				  concludes that lack of the service or item would impair the recipient's health,
				  the practitioner may either give the recipient the prescription or order to
				  take to the CAO, or send the prescription or order to the CAO by
				  mail.
(c) The CAO shall forward the
				  prescription and a completed Form MA 325 (Request for Waiver) to the Office of
				  MA Programs where it will be reviewed by the Department's medical consultants.
				  The Office of MA Programs will notify the requestor of its decision. Section
				  1101.67 (relating to prior
				  authorization) which requires a decision on requests for prior authorization
				  within 21 days does not apply to requests for waivers.
(d) The Department will review each request
				  using the following guidelines:
(1) Payment
				  for the procedure is not allowable according to the fee schedule, is a type of
				  service covered by the program and is generally accepted by the medical
				  community.
(2) The procedure is not
				  experimental.
(3) The therapeutic
				  effectiveness of the procedure has been scientifically documented.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › GENERAL PROVISIONS › Section 1151.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This chapter
				  applies to inpatient psychiatric facilities.
(b) The MA Program provides payment for
				  medically necessary inpatient services rendered to eligible recipients by
				  enrolled inpatient psychiatric facilities. Payment is made subject to this
				  chapter and Chapter 1101 (relating to general provisions).
The provisions of this §
												1151.1 amended under sections 201
						and 443.1(1) of the Public Welfare Code (62 P. S.
						§§
													201 and
						443.1(1)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › SCOPE OF BENEFITS › Section 1151.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients under 21 years of age as
					 defined in §
										1151.2 (relating to definitions)
					 or 65 years of age or older are eligible for medically necessary inpatient
					 psychiatric services provided by a participating inpatient psychiatric
					 facility, subject to this chapter and Chapter 1101 (relating to general
					 provisions).
The provisions of this §
												1151.21 amended under sections
						201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code
						(62
						P. S. §§
													201(2),
						403(b), 443.1, 443.3, 443.6,
						448 and 454).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › SCOPE OF BENEFITS › Section 1151.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients under 21 years of age as defined
					 in §
										1151.2 (relating to definitions)
					 or age 65 or older are eligible for medically necessary inpatient psychiatric
					 services provided by a participating inpatient psychiatric facility, subject to
					 this chapter and Chapter 1101 (relating to general
					 provisions).
The provisions of this §
												1151.22 amended under sections
						201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code
						(62
						P. S. §§
													201(2),
						403(b), 443.1, 443.3, 443.6,
						448 and 454).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › SCOPE OF BENEFITS › Section 1151.23 - 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
					 inpatient psychiatric services unless the recipient is also either
					 categorically needy or medically needy.
The provisions of this §
												1151.23 amended under sections 201
						and 443.1(1) of the Public Welfare Code (62 P. S.
						§§
													201 and
						443.1(1)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › SCOPE OF BENEFITS › Section 1151.24 - Scope of benefits for GA recipients

Current through Register Vol. 54, No. 28, July 13, 2024
(a) GA recipients, age 21 to 65, are eligible
				  for medically necessary inpatient psychiatric services as described in Chapter
				  1101 (relating to general provisions). See § 1101.31(e) (relating to
				  scope).
(b) Inpatient psychiatric
				  services are subject to this chapter and Chapter 1101.
The provisions of this §
												1151.24 amended under sections
						201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code
						(62
						P. S. §§
													201(2),
						403(b), 443.1, 443.3, 443.6,
						448 and 454).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PROVIDER PARTICIPATION › Section 1151.31 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
				  addition to the participation requirements established in Chapter 1101
				  (relating to general provisions), to participate in the MA Program, a private
				  psychiatric hospital shall:
(1) Be licensed by
				  the Department's Office of Mental Health.
(2) Be approved by the Department's Office of
				  Mental Health under Chapter 5100 (relating to mental health
				  procedures).
(3) Have in effect a
				  utilization review plan that meets the requirements at 42 CFR Part 456 ,
				  Subpart D (relating to utilization control: mental hospitals) and
				  42 CFR
				  482.30 (relating to conditions of
				  participation: utilization review) as certified by the Department's Office of
				  MA Programs.
(4) Be accredited by
				  the Joint Commission on Accreditation of Healthcare Organizations
				  (JCAHO).
(5) Be certified by the
				  Department of Health as being in substantial compliance with the Medicare
				  requirements for participation for specialty hospitals at 42 CFR Part 482 ,
				  Subpart E (relating to requirements for specialty hospitals).
(6) Be enrolled in the MA Program as a
				  private psychiatric hospital.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PROVIDER PARTICIPATION › Section 1151.32 - Participation requirements for out-of-State private psychiatric hospitals

Current through Register Vol. 54, No. 28, July 13, 2024
Out-of-State private psychiatric hospitals furnishing care
					 to Commonwealth recipients shall do the following:
(1) Participate in the Medicaid Program of
				  the state in which the hospital is located.
(2) Enroll in the Commonwealth's MA
				  Program.
(3) Be Medicare
				  certified.
(4) Be certified by
				  either the Joint Commission on Accreditation of Healthcare Organizations
				  (JCAHO) or the American Osteopathic Association (AOA).
The provisions of this §
												1151.32 amended under sections 201
						and 443.1(1) of the Public Welfare Code (62 P. S.
						§§
													201 and
						443.1(1)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PROVIDER PARTICIPATION › Section 1151.33 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In addition to the ongoing
				  responsibilities established in Chapter 1101 (relating to general provisions),
				  and as a condition of continued participation in the MA Program, private
				  psychiatric hospitals and general hospitals with distinct part psychiatric
				  units that are reimbursed under this chapter shall:
(1) Maintain transfer agreements with skilled
				  nursing and intermediate care facilities, general hospitals and rehabilitation
				  hospitals, for the prompt and appropriate transfer of patients who no longer
				  require inpatient psychiatric services.
(2) Upon request, promptly furnish accurate
				  copies of patient records and fiscal records to the Department or its agents or
				  to Federal and State auditors.
(3)
				  Retain complete, accurate and auditable medical and fiscal records for 4 years
				  from the date of each admission for every MA recipient.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PROVIDER PARTICIPATION › Section 1151.34 - Changes of ownership or control

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An inpatient psychiatric facility is not
				  entitled to additional reimbursement due solely to change of ownership or
				  control.
(b) If ownership changes,
				  the Department will establish per diem payment rates as follows:
(1) If the change involves only one inpatient
				  psychiatric facility, the Department will use the per diem payment rate
				  assigned to the inpatient psychiatric facility before the change.
(2) If the change combines two or more
				  inpatient psychiatric facilities into a single entity, such as a merger or
				  consolidation, the Department will establish a new per diem payment rate for
				  the new entity by averaging the rates of the previous entities on a
				  days-weighted basis. To determine that days-weighted average, the Department
				  will use the MA days of each previously enrolled inpatient psychiatric facility
				  as reported in the most recent fiscal year for which all the previous entities
				  filed acceptable Cost Reports (MA 336).
(3) If the change divides one enrolled
				  inpatient psychiatric facility into two or more entities, the Department will
				  use the per diem payment rate assigned to the inpatient psychiatric facility
				  before the change, for all resulting entities.
(4) The Department will not rebase rates
				  established under this subsection until it rebases rates Statewide.
(5) If the Department rebases rates Statewide
				  after a change in ownership has occurred, by using a base year which predates
				  or corresponds to the year of the change, the Department will use the Cost
				  Reports (MA 336) and the claims data for the base year regardless of who owned
				  the entity in that base year.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.41 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  This chapter and Chapter 1101 (relating to general provisions) govern payment
				  for inpatient psychiatric facility services.
(b) If a recipient is readmitted to an
				  inpatient psychiatric facility within 24 hours of the recipient's discharge
				  from the same facility, it will not be considered a new admission for MA
				  purposes, but rather a continuation of the original admission.
(c) If a recipient is admitted to an
				  inpatient psychiatric facility and discharged the same calendar day, the
				  Department will do the following:
(1) Pay
				  one-half of the per diem rate determined by the Department for the facility
				  under §
											1151.46 (relating to payment rate
				  calculations for Fiscal Years 1993-94 and 1994-95).
(2) Count the stay as one-half of an
				  inpatient day for cost settlement purposes, for facilities which are subject to
				  cost settlement.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.41a - Clarification of the term "in writing"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term "in writing" in §
										1151.41(j)
				  (relating to general payment policy) includes orders that are handwritten or
				  transmitted by electronic means.
(b) Written orders 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.