reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › SCOPE OF BENEFITS › Section 1121.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are not eligible for
					 pharmaceutical services covered by the MA Program unless one of the following
					 occurs:
(1) If a compensable item or
				  service is prescribed through the School Medical Program as described in §
										1101.32(a)(2)
				  (relating to coverage variations).
(2) If a compensable item or service is
				  prescribed for the purpose of family planning.
(3) If a compensable vaccine is prescribed
				  through the Early and Periodic Screening, Diagnosis and Treatment Program as
				  described in §
										1101.32(a)(1).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › SCOPE OF BENEFITS › Section 1121.23 - 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 medically
					 necessary pharmaceutical services covered by the MA Program, subject to the
					 conditions and limitations of this chapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › SCOPE OF BENEFITS › Section 1121.24 - Scope of benefits for GA recipients

Current through Register Vol. 54, No. 28, July 13, 2024
GA recipients, age 21 to 65, are eligible for medically
					 necessary basic health care benefits as described in Chapter 1101 (relating to
					 general provisions) and this chapter. See §§
										1101.31(e) and
					 1121.11 (relating to scope; and
					 types of services covered).
The provisions of this §
												1121.24 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).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PROVIDER PARTICIPATION › Section 1121.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
Participation requirements are established in §§
										1101.41-1101.43 and
					 1101.51. Each participating
					 pharmacy must be separately enrolled and enter a separate provider
					 agreement.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PROVIDER PARTICIPATION › Section 1121.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the ongoing responsibilities established in
					 Chapter 1101 (relating to general provisions) pharmacies shall, as a condition
					 of participation, comply with the following requirements:
(1) Permit authorized State and Federal
				  officials or their authorized agents to conduct onsite reviews for the purpose
				  of verification of information furnished as a basis for payment under the MA
				  Program and for establishing the pharmacy's usual and customary charge to the
				  general public as defined in Chapter 1101. During the course of the review, the
				  reviewers shall be allowed access to the dispensing area. The provider shall
				  allow reviewers access to records and documents necessary to determine whether
				  payment for services is or was due under the Program and whether services that
				  have been and are being provided comply with Federal and State law. The
				  reviewer shall be allowed to photocopy, or duplicate these records and
				  documents. These records include:
(i) MA
				  prescriptions on file.
(ii) Non-MA
				  prescriptions without the reviewer having access to patient
				  identification.
(iii)
				  Pharmaceutical purchase invoices.
(iv) The pricing system used by the store,
				  including but not limited to, pricing rolodex, patient profile and pricing
				  codes.
(v) Price lists attached to
				  prescription containers.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PAYMENT FOR PHARMACEUTICAL SERVICES › Section 1121.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered pharmaceutical services
					 provided by participating pharmacies subject to the conditions and limitations
					 in this section and §§
										1121.52-1121.56 and Chapter 1101 (relating
					 to general provisions). Payment will not be made for a compensable
					 pharmaceutical service if payment is available from another public agency or
					 another insurance or health program. This does not apply to MA recipients whose
					 drugs have been prescribed through the County Mental Health/Mental Retardation
					 Programs operated under the Mental Health and Mental Retardation Act of 1966
					 (50
					 P. S. §§
											4101-4704). In this
					 instance only, providers may bill the MA Program for services as specified in
					 this chapter.
This section cited in 55 Pa. Code §
												1121.54 (relating to
						noncompensable services and items).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PAYMENT FOR PHARMACEUTICAL SERVICES › Section 1121.52 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) MA prescriptions, including those for
				  recipients in skilled nursing facilities, intermediate care facilities or
				  intermediate care facilities for the mentally retarded, which have been either
				  written or verbally ordered by a licensed prescriber shall contain on the
				  prescription form:
(1) The name and address
				  of the patient.
(2) The name of the
				  licensed prescriber.
(3) The name,
				  strength and quantity of the medication.
(4) The directions for use.
(5) The number of refills, if any.
(6) The indication for "brand medically
				  necessary", when applicable, as specified in §
											1121.53(b)
				  (relating to limitations on payment).
(7) The DEA number of the licensed
				  prescriber, when controlled substances have been prescribed.
(8) The professional license number of the
				  licensed prescriber.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PAYMENT FOR PHARMACEUTICAL SERVICES › Section 1121.52a - Clarification of the term "written"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term "written" in §
										1121.52(a) 
				  (relating to payment conditions for various services) includes 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.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PAYMENT FOR PHARMACEUTICAL SERVICES › Section 1121.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will not pay a provider an amount that exceeds the provider's usual
				  and customary charge to the general public.
(b) The Department establishes a State MAC
				  which sets a limit on the drug cost component of the payment formula for
				  selected multisource drugs. The State MAC will include a combination of CMS
				  multisource drugs and the Department's MAC drugs and does not apply if the
				  following exist:
(1) The licensed prescriber
				  certifies that a specific brand is medically necessary by doing all of the
				  following:
(i) Writes on the prescription form
				  "Brand Necessary" or "Brand Medically Necessary" in the prescriber's own
				  handwriting.
(ii) Receives prior
				  authorization from the Department to use the brand name product.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PAYMENT FOR PHARMACEUTICAL SERVICES › Section 1121.54 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made to a pharmacy for the following
					 services and items:
(1) Drugs and
				  other items prescribed for obesity, appetite control or other similar or
				  related habit altering tendencies. Drugs which have been cleared for use in the
				  treatment of hyperkinesis in children and primary and secondary narcolepsy due
				  to structural damage of the brain are compensable if the physician indicates
				  the diagnosis on the original prescription.
(2) Nonlegend drugs in the form of troches,
				  lozenges, throat tablets, cough drops, chewing gum, mouthwashes and similar
				  items.
(3) Pharmaceutical services
				  provided to a hospitalized person.
(4) Drugs and devices classified as
				  experimental by the FDA or whose use is classified as experimental by the
				  FDA.
(5) Drugs and devices not
				  approved by the FDA or whose use is not approved by the FDA.
(6) Placebos.
(7) Legend and nonlegend soaps, cleansing
				  agents, dentifrices, mouthwashes, douche solutions, diluents, ear wax removal
				  agents, deodorants, liniments, antiseptics, irrigants and other personal care
				  and medicine chest items.
(8)
				  Compounded prescriptions when one of the following applies:
(i) Compensable items are used in less than
				  therapeutic quantities.
(ii)
				  Noncompensable items are compounded.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PAYMENT FOR PHARMACEUTICAL SERVICES › Section 1121.55 - Method of payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will pay a pharmacy for a compensable legend and nonlegend drug
				  (after deducting the applicable copayment amount, as described in §
										1101.63(b) 
				  (relating to payment in full)), the lowest of the following amounts:
(1) The EAC for the drug, multiplied by the
				  number of units dispensed, plus a $2 dispensing fee.
(2) The State MAC for the drug, multiplied by
				  the number of units dispensed, plus a $2 dispensing fee.
(3) The provider's usual and customary charge
				  to the general public.
(4) For MA
				  recipients with a pharmacy benefit resource which is a primary third party
				  payer to MA, the lower of the following amounts:
(i) The EAC for the drug, multiplied by the
				  number of units dispensed, plus a $0.50 dispensing fee.
(ii) The State MAC, multiplied by the number
				  of units dispensed, plus a $0.50 dispensing fee.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › PAYMENT FOR PHARMACEUTICAL SERVICES › Section 1121.56 - Drug cost determination

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  The Department will base its drug cost for compensable legend and nonlegend
				  drugs on the lower of:
(1) The EAC established
				  by the Department.
(i) For brand name drugs,
				  the EAC is established by the Department as one of the following:
(A) The lowest WAC listed for the drug in
				  available Nationally recognized pricing services, plus 3.2%.
(B) If WAC data are not available from a
				  Nationally recognized pricing service, the lowest AWP listed for the drug in
				  available Nationally recognized pricing services, minus 14%.
(C) If both WAC and AWP cost data are
				  available for the drug from a Nationally recognized pricing service, the lower
				  of the two amounts.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › UTILIZATION REVIEW › Section 1121.71 - 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) and §
										1121.42(1)
					 (relating to ongoing responsibilities of providers).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1121 - PHARMACEUTICAL SERVICES › ADMINISTRATIVE SANCTIONS › Section 1121.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  provider determined to have billed for services inconsistent with MA Program
				  regulations, to have provided services outside the scope of customary standards
				  of pharmaceutical practice, or to have otherwise violated the standards in the
				  provider agreement, is subject to the sanctions described in Chapter 1101
				  (relating to general provisions).
(b) Where a provider is subject to subsection
				  (a) or §
										1101.77 (relating to enforcement
				  actions by the Department), the pharmacist responsible for the violations, the
				  owner of the provider at the time of the violation and a person owning 5% or
				  more of shares of stock in the provider at the time of the violation shall be
				  subject to preclusion from indirect participation in the MA Program for the
				  same period as a sanction against the provider. No provider may participate or
				  be enrolled in the MA Program while owned or operated by a person precluded
				  from indirect participation. Ownership includes but is not limited to ownership
				  of 5% or more of the corporate stock of the provider if the provider is
				  incorporated.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › GENERAL PROVISIONS › Section 1123.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for certain medically
					 necessary medical supplies rendered to eligible recipients by approved medical
					 suppliers enrolled as providers under the program. Payment for medical supplies
					 is subject to this chapter, Chapter 1101 (relating to general provisions) and
					 the limitations established in Chapter 1150 (relating to MA Program payments
					 policies) and the MA Program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › GENERAL PROVISIONS › Section 1123.2 - 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:
Durable medical equipment
-An item or
					 device listed in the Medical Assistance program fee schedule that can withstand
					 repeated use; which are used primarily and customarily to serve a medical
					 purpose; which are customarily not useful to a person in the absence of illness
					 or injury and which are appropriate for home use.
Hemophilia products
-Items which are used
					 in the treatment of hemophilia limited to those products listed in the Medical
					 Assistance program fee schedule.
Medical supplies
-Items specified in this
					 chapter or the Medical Assistance program fee schedule as being compensable
					 under the Medical Assistance program. The items include surgical supplies,
					 durable medical equipment, orthoses, prostheses, visual and hearing aids and
					 hemophilia products.
Molded shoes
-Shoes listed in the Medical
					 Assistance program fee schedule constructed from a special last conforming to a
					 specific individual's foot. Molded shoes shall be constructed from leather or
					 other durable material.
Orthopedic shoes
-Shoes listed in the
					 Medical Assistance program fee schedule that have a Goodyear welt, steel shank
					 and elongated medical counter which are modified to compensate for an
					 abnormality of the foot. Various modifications, such as wedges, can be applied
					 to or put inside this basic orthopedic shoe. The Department's established fee
					 for orthopedic shoes includes modifications except for those necessary to apply
					 a brace or splint to the shoe.
Orthoses
-Items listed in the Medical
					 Assistance program fee schedule that are used to support, align, prevent or
					 correct deformities or to improve the functions of movable parts of the
					 body.
Prostheses
-An item which substitutes or
					 replaces missing parts of the body.
Shoe inserts
-Devices listed in the Medical
					 Assistance program fee schedule that are constructed of plexiglass, hard
					 plastic or other rigid material fashioned for the individual foot by a
					 laboratory approved to participate in the Medical Assistance program. An
					 orthotic device shall be fabricated according to the specifications written on
					 the prescription by the client's physician.
Surgical supplies
-An item intended for
					 direct application to the body as an aid to ameliorate a diagnosed medical
					 condition.
Visual aids
-An item which is used to
					 correct or improve the function of the eye.
This section cited in 55 Pa. Code §
												1123.2a (relating to clarification
						of the term "written"-statement of policy); 55 Pa. Code §
												1123.22 (relating to scope of
						benefits for the medically needy); and 55 Pa. Code §
												1123.61 (relating to
						noncompensable services and items).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › GENERAL PROVISIONS › Section 1123.2a - Clarification of the term "written"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term "written" in the definition of
				  "shoe inserts" in §
										1123.2 (relating to definitions)
				  includes 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.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › COVERED AND NONCOVERED SERVICES › Section 1123.11 - Types of services covered

Current through Register Vol. 54, No. 28, July 13, 2024
The Medical Assistance program covers certain medical
					 supplies for which the medical necessity has been established and the service
					 has been prescribed or ordered by a licensed practitioner within the scope of
					 his practice. Payment is subject to the conditions and limitations of this
					 chapter and Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › COVERED AND NONCOVERED SERVICES › Section 1123.12 - Outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
Medical supplies provided on an outpatient basis are
					 covered only when provided in accordance with this chapter, Chapters 1101 and
					 1150 (relating to general provisions; and Medical Assistance program payment
					 policies) and the Medical Assistance program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › COVERED AND NONCOVERED SERVICES › Section 1123.13 - Inpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment is made for compensable medical supplies provided to eligible
				  hospitalized recipients with the exception of surgical supplies and durable
				  medical equipment.
(b) Payment is
				  made for compensable medical supplies provided to eligible recipients in
				  skilled nursing and intermediate care facilities, with the exception of
				  surgical supplies and durable medical equipment.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › SCOPE OF BENEFITS › Section 1123.21 - 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 medical supplies covered by the MA Program subject to the conditions
					 and limitations of this chapter and Chapter 1101 (relating to general
					 provisions). See § 1101.31(b) (relating to scope).
The provisions of this §
												1123.21 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 1123 - MEDICAL SUPPLIES › SCOPE OF BENEFITS › Section 1123.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are not eligible for medical
					 supplies except for the following:
(1)
				  Medical supplies which have been prescribed through the School Medical Program
				  as described in §
										1101.32 (relating to coverage
				  variations).
(2) Eyeglasses which
				  have been prescribed as treatment for individuals under 21 years of age who are
				  enrolled in EPSDT, or which have been prior authorized by the Department as
				  specified in § 1123.56(a)(2) (relating to vision aids).
(3) Devices which have been prescribed for
				  the purpose of family planning.
(4)
				  Those compensable medical supplies suitable for home use that are provided to
				  medically needy recipients who are receiving home health agency services. The
				  supplies include surgical supplies and durable medical equipment as defined in
				  §
										1123.2 (relating to
				  definitions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › SCOPE OF BENEFITS › Section 1123.24 - Scope of benefits for GA recipients

Current through Register Vol. 54, No. 28, July 13, 2024
GA recipients, age 21 to 65, 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).
The provisions of this §
												1123.24 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 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered services provided by
					 participating providers subject to the conditions and limitations established
					 in this section, §§
										1123.52 and
					 1123.60-1123.62, and Chapters 1101 and
					 1150 (relating to general provisions; and MA Program payment policies) and the
					 MA Program fee schedule. Items and services shall be prescribed by a licensed
					 medical practitioner and prescriptions and orders shall specify the patient's
					 diagnosis. Payment will not be made for a compensable medical supply if payment
					 is available from another agency or another insurance or health
					 program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.52 - Payment conditions for various services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for orthopedic shoes, orthotic devices, molded
					 shoes, oxygen and related equipment, visual aids, hearing aids, prosthetic
					 devices and hemophilia products will be made subject to the conditions
					 established in §§ 1123.53-1123.58.
This section cited in 55 Pa. Code §
												1123.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.53 - Hemophilia products

Current through Register Vol. 54, No. 28, July 13, 2024
In order for payment to be made to an approved provider for
					 hemophilia products, the recipient shall be enrolled in the hemophilia program
					 of the Commonwealth.
This section cited in 55 Pa. Code §
												1123.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.54 - Orthopedic shoes, molded shoes and shoe inserts

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for orthopedic shoes, molded shoes and shoe inserts
					 prescribed for eligible persons is paid to approved Medical Assistance
					 providers in accordance with the limitations described in this section and the
					 maximum fees listed in Chapter 1150 (relating to Medical Assistance program
					 payment policies) and the Medical Assistance program fee schedule.
(1) Prior approval shall be obtained from the
				  Department for orthopedic shoes, molded shoes and shoe inserts.
(2) Payment for molded shoes is made only for
				  those shoes prescribed for severe foot and ankle conditions and deformities of
				  a degree that the patient is unable to wear ordinary sturdy shoes with or
				  without corrections and modifications.
(3) Payment for modifications to orthopedic
				  shoes and molded shoes will be made only if those modifications are necessary
				  for the application of a brace or splint.
(4) Payment for repairs to orthopedic and
				  molded shoes is made un-der the Medical Assistance program without a
				  prescription or prior authorization.
(5) Payment for orthopedic shoes is made only
				  if the recipient is 20 years of age or younger.
This section cited in 55 Pa. Code §
												1123.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.55 - Oxygen and related equipment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for oxygen and related equipment
				  will be made only if the patient has had a comprehensive cardiopulmonary
				  evaluation that resulted in an established diagnosis of the cause of the
				  respiratory disability. The prescription shall contain the cardiopulmonary
				  diagnosis.
(b) Prior authorization
				  is required as specified in §
										1101.67 (relating to prior
				  authorization) for the first 45 days of use of oxygen and related equipment
				  unless the physician certifies that the recipient is adequately prepared to use
				  oxygen equipment and the physical surroundings in the home are suitable for its
				  use. Prior authorization is not required for continuing use after the initial
				  45 days providing continued use is prescribed by the practitioner.
(c) Payment will be made only if the
				  physician includes the flow rate per minute and the specific requirements such
				  as mask, cannula and nebulizer on the prescription.
(d) A physician shall recertify orders for
				  oxygen at least every 6 months and recertification shall be kept by the
				  provider.
This section cited in 55 Pa. Code §
												1123.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.56 - Vision aids

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for
				  eyeglasses is made only if the recipient is 20 years of age or younger and the
				  eyeglasses have been one of the following:
(1) Prescribed through EPSDT program as
				  described in §
											1101.32(a)(1)
				  (relating to coverage variations).
(2) Prior authorized by the Department as
				  provided through EPSDT, when screening has not occurred under §
				  1101.32(a)(1).
(3) Prescribed
				  through the School Medical Program as described in §
				  1101.32(a)(2).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.57 - Hearing aids

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for
				  hearing aids is made only if the recipient is 20 years of age or younger and
				  the hearing aids have been:
(1) Prescribed
				  through EPSDT program as described in §
											1101.32(a)(1)
				  (relating to coverage variations).
(2) [Reserved].
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.58 - Prostheses and orthoses

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for prostheses and orthoses may be made only under
					 one of the following:
(1) The
				  recipient is categorically needy.
(2) The prescription has been prior
				  authorized by the Department as specified in §
										1101.67 (relating to prior
				  authorization).
This section cited in 55 Pa. Code §
												1123.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.60 - Limitations on payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Under
				  no circumstances may the provider be paid an amount that exceeds the price the
				  provider currently charges the self-paying public.
(b) Payment will be made for either
				  orthopedic shoes or orthotic devices but not both.
(c) Payment for orthopedic shoes and orthotic
				  devices is subject to the following limitations:
(1) Four pairs of orthopedic shoes, either
				  with or without an attached leg brace per year for those eligible recipients 20
				  years of age or younger.
(2) One
				  pair of orthotic devices every 3 years for those eligible recipients 16 years
				  of age or older. These are not compensable, however, if the recipient has
				  received orthopedic shoes in the 365 days prior to provision of the orthotic
				  device.
(3) Four pairs of orthotic
				  devices every 3 years for those eligible recipients under 16 years of age.
				  These are not compensable, however, if the recipient has received orthopedic
				  shoes in the 365 days prior to provision of the orthotic device.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.61 - 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) Items and services not
				  listed in the Medical Assistance program fee schedule.
(2) Eyeglasses for individuals 21 years of
				  age or older.
(3) Prescription
				  sunglasses.
(4) Tinted
				  lenses.
(5) Tennis shoes, sneakers,
				  slippers, sandals or another type of footwear that does not fit the description
				  of the orthopedic shoe or molded shoe established in §
										1123.2 (relating to
				  definitions).
(6) Surgical supplies
				  and durable medical equipment for persons in skilled nursing and intermediate
				  care facilities.
(7) Repairs or
				  modifications to shoes other than orthopedic shoes as defined in §
										1123.2 except for the insertion of
				  orthotic devices.
(8) Orthotic
				  devices for orthopedic or molded shoes.
(9) Items prescribed or ordered by a
				  practitioner who has been barred or suspended during an administrative action
				  from participation in the Medical Assistance Program. The Department will,
				  periodically, send medical suppliers a list of names of suspended, terminated
				  or reinstated practitioners and the dates of the various actions. Medical
				  suppliers are responsible for checking this list before providing
				  services.
(10) Orthopedic shoes for
				  individuals 21 years of age or older.
This section cited in 55 Pa. Code §
												1123.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › PAYMENT FOR MEDICAL SUPPLIES › Section 1123.62 - Method of payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For
				  medical supplies the medical supplier's maximum payment shall be the lower of
				  either the provider's charge to the self-paying public, the upper limits set by
				  Medicare or Medicaid, or the maximum fees or rates established in Chapter 1150
				  (relating to Medical Assistance program payment policies) and the Medical
				  Assistance program fee schedule.
(b) Rental payments shall be made only for
				  the established period of medical necessity. In the event that the item is to
				  be purchased, rental fee of one month will be applied to the purchase
				  price.
This section cited in 55 Pa. Code §
												1123.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1123 - MEDICAL SUPPLIES › UTILIZATION REVIEW › Section 1123.71 - Scope of claim 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 1123 - MEDICAL SUPPLIES › ADMINISTRATIVE SANCTIONS › Section 1123.81 - 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 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 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › GENERAL PROVISIONS › Section 1126.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program pays for same day surgical services provided
					 to eligible MA recipients. Payment is made to participating, independently
					 operated ambulatory surgical centers and hospital short procedure units under
					 this chapter and Chapter 1101 (relating to general provisions).
This section cited in 55 Pa. Code §
												1126.53 (relating to limitations
						on covered procedures).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › GENERAL PROVISIONS › Section 1126.2 - 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:
ASC-Ambulatory surgical center
-A facility
					 licensed by the Department of Health which provides outpatient surgical
					 treatment. The term does not include individual or group practice offices of
					 private physicians or dentists, unless the offices have a distinct part used
					 solely for outpatient surgical treatment on a regular and organized
					 basis.
SPU-Short procedure unit
-A unit of a
					 hospital organized for the delivery of ambulatory surgical, diagnostic or
					 medical services.
Same day surgical services
-Specified
					 surgical, diagnostic and medical treatment provided to patients who do not
					 require hospitalization, but who require constant medical supervision for a
					 limited amount of time following the procedure performed.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › SCOPE OF BENEFITS › Section 1126.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients not enrolled in health
					 maintenance or health insuring organizations are eligible for ambulatory
					 surgical services, subject to this chapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › SCOPE OF BENEFITS › Section 1126.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients not enrolled in a health
					 maintenance or health insuring organization are eligible for ambulatory
					 surgical services, subject to this chapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › SCOPE OF BENEFITS › Section 1126.23 - 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
					 ambulatory surgical services under the MA Program unless the recipient is also
					 categorically needy or medically needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › SCOPE OF BENEFITS › Section 1126.24 - 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 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › PROVIDER PARTICIPATION › Section 1126.41 - 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), an independently operated ASC or hospital SPU
				  shall:
(1) Be enrolled in the MA Program as
				  an ASC or a hospital SPU.
(2) 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. §§
												101-1503) and applicable
				  licensing statutes.
(3) Have an
				  established schedule of charges for billing third parties and private payors
				  that is published and made available to the general public.
(4) If requested, furnish information to the
				  Department necessary to establish rates as specified in §
											1126.53 (relating to limitations
				  on covered procedures), in the form and manner the Department
				  requires.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › PROVIDER PARTICIPATION › Section 1126.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
Ongoing responsibilities of providers are established in
					 §
										1101.51 (relating to ongoing
					 responsibilities of providers).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › PAYMENT FOR SAME DAY SURGICAL SERVICES › Section 1126.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment is made for support services related to procedures provided by
				  participating ASCs and SPUs. Payment is 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).
(b) A fee determined by the Department is
				  paid to an ASC or an SPU for support services relating to a covered procedure
				  provided to an eligible recipient at the facility.
(c) The ASC or SPU is considered the provider
				  regardless of whether the facility is operated directly by the enrolled
				  provider or through contract between the provider and other organizations or
				  individuals. The enrolled provider is responsible for the delivery of service
				  and for billings.
(d) When two or
				  more compensable procedures are performed during the same ASC or SPU stay, the
				  services relating to the procedure carrying the highest payment shall be paid
				  in full with no allowance for additional procedures.
(e) The fee paid to the facility shall
				  include but is not limited to:
(1) Nursing,
				  technician and related services.
(2) Use of the facility.
(3) Drugs, biologicals, surgical dressings,
				  supplies, splints, casts and appliances and equipment directly related to the
				  provision of surgical procedures.
(4) Administrative, recordkeeping and
				  housekeeping items and services.
(5) Materials for anesthesia.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › PAYMENT FOR SAME DAY SURGICAL SERVICES › Section 1126.52 - Payment criteria

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will establish maximum reimbursement fees for same day surgical
				  services based on the criteria established in §
										1150.62 (relating to payment
				  levels.)
(1) The level of reimbursement will
				  be consistent with efficiency, economy and quality of care.
(2) The level of reimbursement will be
				  sufficient to assure availability of services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › PAYMENT FOR SAME DAY SURGICAL SERVICES › Section 1126.53 - Limitations on covered procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment will be made for same day
				  surgical procedures listed by the department as compensable when provided under
				  §
										1126.1 (relating to
				  policy).
(b) Payment for procedures
				  that are appropriate for same day surgery but are not yet included in the
				  established list of covered ASC/SPU services is limited to:
(1) The specific fee for each procedure
				  developed by the Department when enough data is obtained to establish a
				  fee.
(2) Prior to establishment of
				  a fee, the Statewide average cost of same day surgery developed by the
				  Department.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › PAYMENT FOR SAME DAY SURGICAL SERVICES › Section 1126.54 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department does not pay ASCs and SPUs
				  for services directly or indirectly related to, or in conjunction with:
(1) A service not designated by the
				  Department as appropriate to be performed in an ASC or SPU.
(2) A service that does not conform to the
				  requirements of this chapter.
(3) A
				  sterilization performed on individuals 20 years of age or younger.
(4) A sterilization performed on individuals
				  21 years of age or older who have not signed the Consent Form for Sterilization
				  at least 30 days but not more than 180 days prior to the
				  sterilization.
(5) Abortion
				  procedures performed on individuals if a Physician Certification for an
				  Abortion form has not been completed.
(6) A service provided by an ambulatory
				  surgical center that does not meet the Federal Medicare requirements at
				  42 CFR
				  416 (relating to ambulatory surgical
				  services).
(7) Procedures and
				  medical care performed in connection with sex reassignment.
(8) Medical, dental or surgical procedures
				  which may be provided in a clinic or practitioner's office without undue risk
				  to the patient.
(9) Plastic or
				  cosmetic surgery for beautification purposes-for example, otoplasty for
				  protruding ears or lop ears, rhinoplasty-except for internal nasal
				  deformity-nasal reconstruction, excision of keloids, mammoplasty, silicone or
				  silastic implants, dermabrasion, skin grafts and lipectomy. Plastic surgery is
				  compensable if performed for the purpose of improving the functioning of a
				  deformed body member.
(10) A dental
				  case involving oral rehabilitation or restorative services, except for
				  procedures performed for treatment of a secondary diagnosis, unless:
(i) The nature of the surgery or the
				  condition of the patient precludes the procedure in the dentist's
				  office.
(ii) A physician or dentist
				  has documented in the patient's medical record the medical justification for
				  performing the procedure in an ASC/SPU setting.
(11) Diagnostic tests and procedures that can
				  be performed in a clinic or practitioner's office and diagnostic tests and
				  procedures not related to the diagnosis.
(12) Services and items for which full
				  payment equal to or in excess of the Medical Assistance fee, is available
				  through Medicare, other financial resources or other health insurance
				  programs.
(13) Services and items
				  not ordinarily provided to the general public.
(14) A diagnostic or therapeutic procedure
				  solely for experimental, research or educational purposes.
(15) A procedure that is not listed under the
				  Medical Assistance Fee Schedule.
(16) A service that is not medically
				  necessary.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES › PAYMENT FOR SAME DAY SURGICAL SERVICES › Section 1126.55 - Payment conditions for sterilizations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for certified sterilization
				  procedures provided at ASCs/SPUs is made only if:
(1) The individual requesting sterilization
				  has voluntarily given informed consent under subsection (b).
(2) The individual is 21 years of age or
				  older at the time informed consent is obtained.
(3) The individual is not a mentally
				  incompetent individual or an institutionalized individual. For the purposes of
				  this chapter, a mentally incompetent individual is a person who has been
				  declared mentally incompetent by a Federal, State or local court of competent
				  jurisdiction unless that person has been declared competent for purposes which
				  include the ability to consent to sterilization.