Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › PAYMENT FOR SERVICES › Section 1150.51 - General payment policies

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment will be made to providers. Payment may be made to practitioners'
				  professional corporations or partnerships if the professional corporation or
				  partnership is composed of like practitioners. Payment will be made directly to
				  practitioners if they are members of professional corporations or partnerships
				  composed of unlike practitioners. Practitioners who render services at eligible
				  provider hospitals, either through direct employment or through contract, may
				  direct that payment be made to the eligible provider hospital. Payment will be
				  made for medical services or items covered by the program, furnished by
				  enrolled providers subject to the conditions and limitations established in
				  this chapter, Chapter 1101 (relating to general provisions) and the specific
				  chapters for each provider type. Payment will not be made for a covered medical
				  service or item if payment is available from another agency or another
				  insurance or health program. Payment will not be made for services that are not
				  medically necessary.
(b) To the
				  extent that this chapter conflicts with the regulations that relate to
				  reimbursement for various services or items contained in the specific MA
				  provider chapters which were in effect on January 1, 1983, this chapter
				  controls. To the extent that this chapter does not address a reimbursement
				  question answered by a regulation contained in a specific provider chapter, the
				  regulation in the specific provider chapter controls.
(c) This chapter shall be used by
				  practitioners, hospitals providing outpatient and emergency room services,
				  facilities and practitioners rendering services which require a PSR or second
				  opinion, or both; independent clinics; and other noninstitutional providers
				  including medical supplies, independent laboratories, ambulance companies,
				  pharmacies, portable X-ray providers, funeral directors and home health
				  agencies.
(d) Each section of the
				  MA Program Fee Schedule which is contained in the Provider's Handbook includes
				  the following:
(1) An all-inclusive listing of
				  covered services and items.
(2) The
				  provider type eligible under MA to bill for each service and item.
(3) The appropriate procedure code for each
				  service or item.
(4) The
				  appropriate type of service for each procedure code.
(5) The applicable limitations for each
				  service or item.
(6) The maximum
				  allowable fee for each service or item.
(7) For surgical and obstetrical procedures,
				  the allowable number of postoperative or postpartum days during which no
				  additional payment will be made for office or home visits for a purpose other
				  than early and periodic screening, diagnosis and treatment visits to the
				  practitioner who performed the procedure. This policy does not apply to other
				  members of a group practice of a different specialty.
(8) The maximum allowable fee for anesthesia
				  for each procedure.