reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1189.106 - Adjustments relating to sanctions and fines

Current through Register Vol. 54, No. 28, July 13, 2024
County nursing facility payments shall be withheld, offset,
					 reduced or recouped as a result of sanctions and fines in accordance with
					 Chapter 1187, Subchapter I (relating to enforcement of compliance for nursing
					 facilities with deficiencies).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1189.107 - Adjustments relating to errors and corrections of county nursing facility payments

Current through Register Vol. 54, No. 28, July 13, 2024
County nursing facility payments shall be withheld, offset,
					 increased, reduced or recouped as a result of errors, fraud and abuse or
					 appeals under Chapter 1187, Subchapter I (relating to enforcement of compliance
					 for nursing facilities with deficiencies) and §
										1189.141 (relating to county
					 nursing facility's right to appeal and to a hearing).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1189.108 - County nursing facility supplementation payments

Current through Register Vol. 54, No. 28, July 13, 2024
Supplementation payments are made according to a formula
					 established by the Department to county nursing facilities, in which Medicaid
					 funded resident days account for at least 80% of the facility's total resident
					 days and the number of certified MA beds is greater than 270 beds. Payment of
					 the supplementation payments is contingent upon the determination by the
					 Department that there are sufficient State and Federal funds appropriated to
					 make these supplementation payments.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter F - RIGHT OF APPEAL › Section 1189.141 - County nursing facility's right to appeal and to a hearing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A county
				  nursing facility has a right to appeal and have a hearing if the county nursing
				  facility does not agree with the Department's decision regarding:
(1) The Department's denial, nonrenewal or
				  termination of the county nursing facility's MA provider agreement.
(2) The Department's imposition of sanctions
				  or fines on the county nursing facility under Chapter 1187, Subchapter I
				  (relating to enforcement of compliance for nursing facilities with
				  deficiencies).
(3) The per diem
				  rate established by the Department.
(4) Other written orders or decisions of the
				  Department that cause the county nursing facility to be aggrieved for purposes
				  of 67 Pa.C.S. Chapter 11 (relating to Medical Assistance hearings and
				  appeals).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › GENERAL PROVISIONS › Section 1221.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for clinic and emergency
					 room services rendered to eligible recipients by hospital clinics and emergency
					 rooms, medical school clinics and independent clinics that are enrolled as
					 providers under the program. Payment is subject to this chapter and Chapters
					 1101 and 1150 (relating to general provisions; and MA Program payment policies)
					 and the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › SCOPE OF BENEFITS › Section 1221.21 - 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 services prescribed by a physician and provided in a clinic or
					 emergency room 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 1221 - CLINIC AND EMERGENCY ROOM SERVICES › SCOPE OF BENEFITS › Section 1221.22 - 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 services prescribed by a physician and provided in a clinic or
					 emergency room 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 1221 - CLINIC AND EMERGENCY ROOM SERVICES › SCOPE OF BENEFITS › Section 1221.23 - 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 clinic
					 and emergency room services. Blind and visually impaired individuals, however,
					 are eligible for services if they qualify as categorically needy or medically
					 needy recipients.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › SCOPE OF BENEFITS › Section 1221.24 - 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 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PROVIDER PARTICIPATION › Section 1221.41 - 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) clinics and hospital emergency rooms shall:
(1) Have an established fee schedule for
				  billing third parties and private payors.
(2) Have a patient referral process that
				  ensures follow up treatment by other physicians or appropriate
				  specialists.
(3) Abide by
				  applicable Federal and State statutes and regulations, including but not
				  limited to Title XIX of the Social Security Act (42 U.S.C.A. §§
												1396-1396p), the Public Welfare Code
				  (62
				  P. S. §
												443.1 et seq.) and applicable
				  licensing statutes.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PROVIDER PARTICIPATION › Section 1221.42 - Additional participation requirements for hospital clinics and emergency rooms

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements listed in
					 §
										1221.41 (relating to participation
					 requirements) hospital outpatient clinics and hospital emergency rooms
					 shall:
(1) Be operated by the hospital
				  directly or under written contract with private physicians or physician group
				  practice.
(2) Be part of an
				  institution that is licensed/approved as a hospital by the Department of Health
				  and that meets the requirements for participation in Medicare.
(3) Be organizationally integrated with the
				  inpatient services of the hospital and have the authority to admit patients to
				  the hospital.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PROVIDER PARTICIPATION › Section 1221.43 - Participation requirements for hospital clinics and emergency rooms for higher reimbursement rate

Current through Register Vol. 54, No. 28, July 13, 2024
To be eligible to bill for the higher MA fee identified in
					 Chapter 1150 (relating to MA Program payment policies) and the MA Program fee
					 schedule outpatient hospital clinics and emergency rooms shall:
(1) Provide comprehensive medical services
				  for a minimum of 40 hours per week. Outpatient hospital clinics meet this
				  requirement if the outpatient department of the hospital is open and provides
				  some clinic service 40 hours per week.
(2) Have a licensed physician present in the
				  clinic or emergency room at all times during scheduled hours of operation to
				  perform medical services. A physician shall be responsible for the overall
				  management of patient care.
(3) Be
				  approved by the Department for higher reimbursement rate.
The provisions of this §
												1221.43 issued under section
						443.3(1) of the
						Public Welfare Code (62 P. S. §
													443.3(1)).
This section cited in 55 Pa. Code §
												1221.45 (relating to additional
						participation requirements for medical school
						clinics).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PROVIDER PARTICIPATION › Section 1221.44 - Additional participation requirements for independent clinics

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements listed in
					 §
										1221.41 (relating to participation
					 requirements), independent medical clinics shall:
(1) Be currently receiving funds or have
				  received initial start-up funds through Federal public health service programs
				  such as the Community Health Center Program (42 U.S.C.A. §
											254c), Migrant Health Program (42 U.S.C.A. §
											254b), National Health Service Corps
				  (42 U.S.C.A. §
											254d) or the Appalachian Regional Development
				  Program (40 U.S.C.A.
				  §§
											202 and
				  214) or through the Department of
				  Health's Division of Primary Health Care Development.
(2) Provide services either directly by a
				  physician or under the supervision of a physician. This means that one or more
				  physicians shall be on staff to either provide directly or supervise the
				  provision of services. If a physician does not provide services directly, then
				  the services shall be provided by a certified registered nurse practitioner
				  within the scope of the Medical Practice Act of 1974 (63 P. S.
				  §§
											421.1-421.18) and the
				  Professional Nursing Law (63 P. S. §§
											211-225) or by a physician assistant within
				  the scope of the Medical Practice Act of 1974 (63 P. S. §§
											421.1-421.18) or the Osteopathic Medical
				  Practice Act (63 P. S. §§
											271.1-271.18).
(3) Provide medical services for a minimum of
				  40 hours per week.
(4) Not limit
				  the number of patients it serves by virtue of the payment source.
(5) Provide direct emergency medical care
				  and, through formal agreements, provide for access to health care for medical
				  emergencies during and after the regularly scheduled hours of the
				  clinic.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PROVIDER PARTICIPATION › Section 1221.45 - Additional participation requirements for medical school clinics

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements listed in
					 §
										1221.41 (relating to participation
					 requirements) medical school clinics shall:
(1) Meet requirements set forth in §
										1221.43(1) and
				  (2) (relating to participation requirements
				  for hospital clinics and emergency rooms for higher reimbursement
				  rate).
(2) Have an agreement with a
				  hospital to serve as the outpatient department of the hospital.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PROVIDER PARTICIPATION › Section 1221.46 - 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 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PAYMENT FOR CLINIC AND EMERGENCY ROOM SERVICES › Section 1221.52 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
In order for payment to be made for a clinic visit or for
					 emergency room services, the following conditions shall be met:
(1) The services shall be provided at the
				  clinic or emergency room site.
(2)
				  The services shall be provided by, or under the supervision of a
				  physician.
(3) Payment for the
				  service shall not be available through another public or private
				  agency.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PAYMENT FOR CLINIC AND EMERGENCY ROOM SERVICES › Section 1221.55 - Payment conditions for sterilizations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for covered sterilization
				  procedures shall be made 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 §
				  1221.2 (relating to definitions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PAYMENT FOR CLINIC AND EMERGENCY ROOM SERVICES › Section 1221.57 - Payment conditions for necessary abortions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Coverage for abortions funded under the
				  MA 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. Payment will be made only if a "Physician
				  Certification for an Abortion" form, signed by a licensed physician, is
				  submitted with the Medical Services Invoice. A sample of the required
				  "Physician Certification for an Abortion" form appears in the provider handbook
				  with instructions for its completion.
(2) Where the recipient was the victim of
				  rape or incest and the incident was reported to a law enforcement agency or to
				  a public health service within 72 hours of its occurrence in the case of rape
				  and within 72 hours of the time the physician notified the patient that she was
				  pregnant in the case of incest. A law enforcement agency means an agency or
				  part of an agency that is responsible for the enforcement of the criminal laws,
				  such as a local police department or sheriff's office. A public health service
				  means an agency of the Federal, State or local government or a facility
				  certified by the Federal government as a Rural Health Clinic that provides
				  health or medical services except for those agencies whose principal function
				  is the performance of abortions.
(i) Payment
				  will be made if a "Physician Certification for an Abortion" form is submitted
				  with the Medical Services Invoice along with documentation signed by an
				  official of the law enforcement agency or public health service to which the
				  rape or incest was reported. The documentation must include the following:
(A) Information specified in subparagraph
				  (ii).
(B) A statement that the
				  report was signed by the person making the report.
(ii) The report of the rape or incest need
				  not be made by the victim herself but can be reported by another person. The
				  report need not be made in person but may be made by mail. The report itself
				  shall be signed by the person who reports the rape or incest and shall include
				  the following information:
(A) The name and
				  address of the victim.
(B) The name
				  and address of the person who made the report if different from the
				  victim.
(C) The date of the
				  incident if it was rape.
(D) The
				  date the report was made.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PAYMENT FOR CLINIC AND EMERGENCY ROOM SERVICES › Section 1221.58 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
The following limits apply to payment for compensable
					 services:
(1) Prenatal visits shall be
				  limited to 12 per pregnancy. Complications attributable to pregnancy may not be
				  counted as part of the 12 prenatal visits but are classified for invoicing
				  purposes as acute illness.
(2) The
				  physician's component for an emergency room visit may be either an emergency
				  room physician's service fee, emergency or nonemergency or the fee for a
				  specific compensable procedure. No payment may be made for the emergency room
				  physician's service fee if a specific compensable procedure is billed for the
				  same emergency room visit. Only those services noted in §
										1221.51(7) 
				  (relating to general payment policy) shall be compensable in addition to either
				  the emergency room physician's service fee or the fee for a specific
				  compensable procedure. Two or more specific compensable surgical procedures
				  performed at the same time shall be paid in accordance with §
				  1221.51(8).
(3) The flat visit fee
				  shall not be paid if a specific compensable procedure is billed for the same
				  hospital, medical school or independent clinic visit. Only those services noted
				  in §
										1221.51(7) shall
				  be compensable in addition to either the flat visit fee or fee for specific
				  compensable procedure. Two or more specific compensable surgical procedures
				  performed at the same time shall be paid in accordance with §
				  1221.51(8).
(4) Payment for
				  physicians' services performed in a hospital clinic, medical school clinic,
				  independent clinic or hospital emergency room shall be subject to the
				  limitations and provisions of Chapter 1141 (relating to physicians'
				  services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PAYMENT FOR CLINIC AND EMERGENCY ROOM SERVICES › Section 1221.59 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made to clinics or emergency rooms for
					 the following services or items:
(1)
				  Services rendered in the hospital emergency room to a recipient who is admitted
				  to the hospital the same day.
(2)
				  Services and procedures that are available through other public agencies or
				  private insurance plans.
(3)
				  Physicians' services not listed in the MA Program Fee Schedule.
(4) Methadone maintenance.
(5) Prescribed medications and medical
				  supplies. Payment for these services is made only to participating pharmacies
				  and medical suppliers. Section
				  1221.51(1)
				  (relating to general payment policy) describes an exception for specific
				  vaccines provided in hospital outpatient clinics, if the hospital does not have
				  a pharmacy enrolled in the MA Program, and independent medical/surgical
				  clinics.
(6) Laboratory services.
				  Payment for these services will be made only to participating
				  laboratories.
(7) Surgical
				  procedures and medical care provided in connection with sex reassignment. This
				  includes, hormone therapy and release of vaginal adhesions.
(8) More than one flat visit fee or fee for a
				  specific compensable service provided by an independent medical clinic,
				  hospital outpatient department, medical school outpatient department or
				  hospital emergency room on the same day, regardless of specialty, except as
				  noted in § 1221.51(6) and (7).
(9) Nonemergency use of the emergency room.
				  Services to patients who do not exhibit symptoms or have a diagnosis that is
				  listed in Appendix A are not reimbursable unless the recipient declares that he
				  does not have access to a primary care physician or an outpatient clinic to
				  treat nonemergency situations. The hospital emergency room staff and the
				  emergency room physician shall document in the patient's medical record the
				  declaration of no access to primary care.
The provisions of this §
												1221.59 amended under sections
						201(2) and 443.3 of the Public Welfare Code (62 P. S. §§
													201(2) and
						443.3).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › UTILIZATION CONTROL › Section 1221.71 - 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 1221 - CLINIC AND EMERGENCY ROOM SERVICES › ADMINISTRATIVE SANCTIONS › Section 1221.81 - 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 1221 - CLINIC AND EMERGENCY ROOM SERVICES › ADMINISTRATIVE SANCTIONS › Appendix A - MEDICAL EMERGENCY CARE SYMPTOMS

Current through Register Vol. 54, No. 28, July 13, 2024
MEDICAL EMERGENCY
CARE SYMPTOMS
Allergy Reactions, Acute (Except Allergy
							 Tests)
Glaucoma, Severe Headache, Severe
Appendicitis, Acute
Heart Attack,
							 Suspected
Asthma, Acute
Hemorrhage
Breathing Difficulties or Shortness of
							 Breath
Hysteria Insulin Shock (Overdose)
Bronchitis, Severe
Kidney Stones
Bursitis, Severe Onset
Maternity
							 Complications, such
Chest Pain, Severe
as Suspected
							 Miscarriage
Choking
Pain, Sudden or Severe Onset
Colitis
Pleurisy
Coma
Pneumonitis
Convulsions and/or Seizures
Poisoning
							 (including overdose)
Cystitis
Pyelitis
Dermatitis or Hives (Resulting from Internal or
							 Unknown Causes)
Pyelonephritis (Shock) Spasms, Cerebral or Cardiac
							 Spontaneous Pneumothorax
Diabetic Coma
Stomach Pains, Severe
Diarrhea, Severe
Strangulated Hernia
Drug Reaction
Stroke
Earache, Severe
Sunstroke
Epistaxis (nosebleed)
Swollen Ring
							 Finger
Fainting
Tachycardia
Fecal Impaction, Severe
Thrombosis and/or
							 Phlebitis
Food Poisoning
Unconsciousness
Frost Bite
Urinary Retention, Acute
Gall Bladder, Acute Attack
Vision loss,
							 Sudden Onset
Gastritis
Vomiting, Severe
Gastro-intestinal Conditions Acute
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › GENERAL PROVISIONS › Section 1223.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific medically
					 necessary outpatient drug and alcohol clinic services rendered to eligible
					 recipients by drug/alcohol outpatient clinics enrolled as providers under the
					 program. Payment for drug/alcohol outpatient clinic 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 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › GENERAL PROVISIONS › Section 1223.2 - 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:
Chemotherapy clinic visit
-A minimum
					 15-minute visit only for administration of a drug for purposes other than
					 methadone maintenance or opiate detoxification, and evaluation of a patient's
					 physical and mental condition during the course of prescribed medication. This
					 visit is provided to an eligible recipient by a licensed physician or by
					 drug/alcohol medical personnel under the supervision of a physician in an
					 approved drug/alcohol outpatient clinic.
Comprehensive medical examination
-An
					 initial examination and evaluation by a licensed physician. The term includes a
					 complete physical examination, comprehensive medical and drug/alcohol history,
					 evaluation of pertinent diagnostic information necessary to formulate a
					 diagnosis and treatment plan and recommendations for treatment or further
					 diagnostic studies or consultation.
DAAP
-
Drug and alcohol addictions
					 professional
-One of the following:
(i) An individual who is certified as an
				  addictions counselor by a Statewide certification body and who is a member of a
				  National certification body.
(ii)
				  An individual who is certified by another state government's substance abuse
				  counseling certification board.
(iii) An individual possessing a minimum of a
				  bachelor's degree in social science and 2 years experience in treatment/case
				  management services for persons with substance abuse/addiction
				  disorders.
(iv) An individual
				  meeting the qualifications of one of the following:
(A) Drug and Alcohol Case Management
				  Specialist.
(B) Drug and Alcohol
				  Case Management Specialist Trainee.
(C) Drug and Alcohol Case Management
				  Supervisor.
(D) Drug and Alcohol
				  Counselor.
(E) Drug and Alcohol
				  Counselor Assistant.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › COVERED AND NONCOVERED SERVICES › Section 1223.11 - Types of services covered

Current through Register Vol. 54, No. 28, July 13, 2024
Medical Assistance Program coverage for outpatient
					 drug/alcohol clinics is limited to professional medical and psychiatric
					 services for the diagnosis and treatment of drug/alcohol abuse and dependence,
					 as specified in the fee schedule in the Medical Assistance program fee
					 schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › COVERED AND NONCOVERED SERVICES › Section 1223.12 - Outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
The outpatient drug/alcohol clinic services specified in
					 the Medical Assistance program fee schedule are covered only when provided by
					 approved drug/alcohol outpatient clinics, when ordered by a licensed physician,
					 to eligible outpatient recipients by or under the supervision of a licensed
					 physician. Payment is limited to the services and subject to the conditions and
					 limitations specified in Chapter 1150 (relating to Medical Assistance program
					 payment policies) and the Medical Assistance program fee schedule, this chapter
					 and Chapter 1101 (relating to general provisions). The Medical Assistance
					 program is not considered to be a funding source for facility, project, program
					 or Single County Authority maintenance or expansion but a program of fee for
					 service reimbursement for actual covered medical and psychiatric services
					 rendered to eligible outpatients in approved clinics.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › COVERED AND NONCOVERED SERVICES › Section 1223.13 - Inpatient hospital services

Current through Register Vol. 54, No. 28, July 13, 2024
For inpatient acute care hospital services refer to Medical
					 Assistance regulations for inpatient hospital services. With the exception of
					 acute care hospital services, drug/alcohol treatment institution services or
					 services to residents of treatment institutions are not covered under the
					 Medical Assistance program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › SCOPE OF BENEFITS › Section 1223.21 - Scope of services for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for the full
					 range of drug/alcohol outpatient clinic services in the MA Program fee
					 schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › SCOPE OF BENEFITS › Section 1223.22 - Scope of services for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for the full range
					 of drug/alcohol outpatient clinic service in the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › SCOPE OF BENEFITS › Section 1223.23 - Scope of services for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are eligible for the full
					 range of drug/alcohol outpatient clinic services in the MA Program fee
					 schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › SCOPE OF BENEFITS › Section 1223.24 - 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 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › PROVIDER PARTICIPATION › Section 1223.41 - 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), drug/alcohol outpatient
					 clinics shall meet the following participation requirements:
(1) Be fully or provisionally
				  licensed/approved as an outpatient drug/alcohol facility by the Department of
				  Health. To remain eligible for Medical Assistance reimbursement, a facility
				  shall be fully or provisionally licensed/approved at all times as an outpatient
				  drug/alcohol clinic.
(2) Have
				  medical personnel currently licensed or registered in accordance with the laws
				  of the Commonwealth.
(3) Have a
				  written patient referral plan that provides for inpatient hospital care and
				  other follow-up treatment.
(4) Post
				  a current, written fee schedule for billing third party and private
				  payors.
(5) Appoint an
				  administrator or director responsible for the internal operation of the clinic
				  in accordance with established policies. Appoint a physician responsible for
				  the supervision and direction of services rendered to eligible
				  recipients.
(6) Notify immediately
				  the Department's Office of Medical Assistance Programs, in writing, of any
				  facility name, address and service changes prior to the effective date of
				  change. Failure to do so may result in payment interruptions or termination of
				  the provider agreement.
(7) Enter
				  into a written provider agreement with the Department.
(8) Forward copies of items required by
				  subparagraphs (i)-(v) to the Office of Medical Assistance Programs. It is the
				  clinic director's responsibility to notify the Office of Medical Assistance
				  Programs, in writing, of changes in the clinic's full compliance with licensure
				  standards and changes in the following items required by subparagraphs (i)-(v)
				  within 30 days following a change. If the clinic is relicensed by the
				  Department of Health, the clinic director shall also forward a copy of the
				  current license to the Office of Medical Assistance Programs within 30 days of
				  relicensure:
(i) A current Department of
				  Health license showing effective dates of licensure and activities
				  licensed.
(ii) A written
				  description of referral services utilized.
(iii) A written description of clinic
				  services provided on the clinic premises.
(iv) The current fee schedule for billing
				  third party and private payors.
(v)
				  The names and business addresses of physicians providing treatment or
				  supervision for MA recipients on a full-time or part-time basis in the
				  clinic.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › PROVIDER PARTICIPATION › Section 1223.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Ongoing
				  responsibilities.
Ongoing responsibilities of providers are
				  established in Chapter 1101 (relating to general provisions).
(b)
Record keeping
				  requirements.
In addition to the requirements listed in Chapter 1101,
				  the following items shall be included in medical records of Medical Assistance
				  patients receiving drug/alcohol outpatient clinic services:
(1) As part of the treatment plan, the
				  treatment plan goals; services to be provided to the patient in the clinic or
				  through referral; and persons to directly provide each service shall be
				  included.
(2) As part of the
				  progress notes, the frequency and duration of each service provided shall be
				  included.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › PAYMENT FOR OUTPATIENT DRUG/ALCOHOL CLINIC SERVICES › Section 1223.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for medically necessary professional
					 medical and psychiatric services provided by or under the supervision and
					 direction of a licensed physician in participating outpatient drug/alcohol
					 clinics, subject to the conditions and limitations established in this chapter
					 and Chapters 1101 and 1150 (relating to general provisions; and Medical
					 Assistance program payment policies) and the Medical Assistance program fee
					 schedule. Payment will not be made for a compensable outpatient drug/alcohol
					 clinic service if payment is available from another public agency or another
					 insurance or health program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › PAYMENT FOR OUTPATIENT DRUG/ALCOHOL CLINIC SERVICES › Section 1223.52a - Requirements for clinic supervisory physician reviews and reevaluations of diagnoses, treatment plans and updates-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will consider a physician to be "in the
					 clinic" under §
										1223.52(a)(6)(iii) and
					 (7)(ii) (relating to payment conditions for
					 various services) when the physician is physically present in a licensed site
					 of the same "project" as defined in 28 Pa. Code §
										701.1 (relating to general
					 definitions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › PAYMENT FOR OUTPATIENT DRUG/ALCOHOL CLINIC SERVICES › Section 1223.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is subject to the following service limitations:
(1) One 15-minute clinic visit per
				  day provided an eligible recipient. Payment will be made for only one of the
				  following if more than one compensable service is provided in one 24-hour
				  period: methadone maintenance clinic visit, chemotherapy clinic visit,
				  drug-free clinic visit or opiate detoxification clinic visit. If psychotherapy
				  is provided on the same day as a clinic visit, payment will be made only for
				  the psychotherapy.
(2) Seven
				  methadone maintenance clinic visits per patient per week for as long as the
				  patient requires methadone maintenance as determined by his physician and
				  documented in the patient's medical record.
(3) Forty-two opiate detoxification clinic
				  visits per patient per 365-day period for the purpose of outpatient, ambulatory
				  opiate detoxification.
(4) A total
				  of three chemotherapy or drug-free clinic visits per patient in a 30-day period
				  for patients not on methadone maintenance or receiving opiate
				  detoxification.
(5) Eight total
				  hours of psychotherapy per patient per 30-day period. This total applies to all
				  psychotherapy: individual, family and group.
(6) One psychiatric evaluation or
				  comprehensive medical evaluation per patient per 365-day period. Either the
				  psychiatric evaluation or the comprehensive medical evaluation may be billed in
				  a 365-day period; payment will only be made for one evaluation in one 365-day
				  period.
(7) One comprehensive
				  diagnostic psychological evaluation or up to an $80 maximum worth of individual
				  psychological or intellectual evaluations per patient per 365-day
				  period.
The provisions of this §
												1223.53 amended under sections
						403(a) and (b), 443.3(1) and 509 of the Public Welfare Code (62 P. S.
						§§
													403(a) and (b),
						443.3(1) and
						509).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › PAYMENT FOR OUTPATIENT DRUG/ALCOHOL CLINIC SERVICES › Section 1223.54 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for the following services and
					 items:
(1) Noncovered services listed
				  in §
										1223.14 (relating to noncovered
				  services).
(2) Items and services
				  not listed as compensable in Chapter 1150 (relating to the Medical Assistance
				  program payment policies) and the Medical Assistance program fee
				  schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › UTILIZATION REVIEW › Section 1223.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
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 1223 - OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES › ADMINISTRATIVE SANCTIONS › Section 1223.81 - 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 imposed in Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › GENERAL PROVISIONS › Section 1225.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for family planning
					 services provided to eligible recipients by hospital outpatient family planning
					 clinics and independent family planning clinics enrolled as providers under the
					 program. Payment for family planning clinic services is subject to this chapter
					 and Chapters 1101 and 1150 (relating to general provisions; and MA Program
					 payment policies) and the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › GENERAL PROVISIONS › Section 1225.2 - 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:
CRNP-Certified registered nurse
					 practitioner
-An individual currently certified by the State Board of
					 Medicine and the State Board of Nursing as a CRNP within the scope of the
					 Medical Practice Act of 1974 (63 P. S. §§
											421.1-421.18) (Repealed).
FPIS-Family planning invoicing system
-A
					 computerized billing system whereby the Family Planning Council or family
					 planning clinic receives payment for several levels of family planning
					 examinations, specific laboratory tests performed at the clinic site and for
					 dispensing specific family planning drugs and devices at the clinic
					 site.
Family planning services
-Diagnosis,
					 treatment, drugs, supplies and related counseling which are provided to
					 individuals of child bearing age to enable the individuals to determine freely
					 the number and spacing of their children.
Hospital outpatient family planning
					 clinic
-A hospital affiliated facility that provides family planning
					 services on an outpatient basis.
Independent family planning clinic
-A
					 free-standing facility operated by a public or private organization which
					 provides family planning services on an outpatient basis.
Physician
-An individual currently licensed
					 by the State Board of Medicine or the State Board of Osteopathic Medicine to
					 practice medicine and surgery under section 10 of the Medical Practice Act of
					 1974 (63 P. S. §
											421.10)
					 (Repealed) or the Osteopathic Medical Practice Act (63 P. S. §§
											271.1-271.18).
Physician assistant
-An individual
					 currently certified by the State Board of Medicine or the State Board of
					 Osteopathic Medicine as a physician assistant within the scope of the Medical
					 Practice Act of 1974 (63 P. S. §§
											421.1-421.18) (Repealed) or the Osteopathic
					 Medical Practice Act (63 P. S. §§
											271.1-271.18).
Registered nurse
-An individual currently
					 licensed in this Commonwealth by the State Board of Nursing to practice
					 professional nursing within the scope of the Professional Nursing Law
					 (63
					 P. S. §§
											211-225).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › SCOPE OF BENEFITS › Section 1225.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for the family
					 planning services listed in MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › SCOPE OF BENEFITS › Section 1225.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for the family
					 planning services listed in the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › SCOPE OF BENEFITS › Section 1225.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are eligible for the family
					 planning services listed in the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › SCOPE OF BENEFITS › Section 1225.24 - 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 1225 - FAMILY PLANNING CLINIC SERVICES › PROVIDER PARTICIPATION › Section 1225.41 - General 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) and the applicable
					 participation requirements listed in §§
										1225.42,
					 1225.43 and
					 1225.45 (relating additional
					 requirements for hospital outpatient family planning clinics; additional
					 requirements for independent family planning clinics; and ongoing
					 responsibilities of providers) hospital outpatient family planning clinics and
					 independent family planning clinics shall meet the following participation
					 requirements:
(1) Have a patient
				  referral system that ensures follow up treatment by other physicians or
				  appropriate specialists.
(2) Be
				  certified as a family planning clinic by the Office of Social Programs, Family
				  Planning Division.
This section cited in 55 Pa. Code §
												1225.42 (relating to additional
						requirements for hospital outpatient family planning clinics); and 55 Pa. Code
						§
												1225.43 (relating to additional
						requirements for independent family planning
						clinics).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1225 - FAMILY PLANNING CLINIC SERVICES › PROVIDER PARTICIPATION › Section 1225.42 - Additional requirements for hospital outpatient family planning clinics

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In addition to
				  the participation requirements listed in §
										1225.41 (relating to general
				  participation requirements) hospital outpatient family planning clinics shall
				  meet the following participation requirements:
(1) Be part of an institution formally
				  licensed as a hospital by the Department of Health.
(2) Be organizationally integrated with
				  inpatient services and have the authority to independently admit patients to
				  the hospital.