reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › PAYMENT FOR PODIATRISTS' SERVICES › Section 1143.53 - Payment conditions for outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Services a podiatrist provides in a Short
				  Procedure Unit (SPU) are compensable to the podiatrist only if the SPU is
				  approved by the Department, the podiatrist is not employed by the hospital for
				  inpatient services, and the service cannot be performed in the podiatrist's
				  office or the emergency room of a hospital without endangering the life or
				  health of the patient.
(b)
				  Specialists' examinations and consultations require prior authorization from
				  the County Assistance Office as described in §
										1101.67 (relating to prior
				  authorization).
This section cited in 55 Pa. Code §
												1143.51 (relating to general
						payment policy); and 55 Pa. Code §
												1143.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › PAYMENT FOR PODIATRISTS' SERVICES › Section 1143.54 - Payment conditions for inpatient hospital services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment is made for inpatient medical
				  services if the condition of the patient requires hospitalization, the patient
				  requires medical management by the podiatrist and surgery is not
				  performed.
(b) An inpatient
				  consultation by a second practitioner is compensable if the condition of the
				  patient requires the service and if the consultation is requested by the
				  podiatrist or physician in charge of the case.
This section cited in 55 Pa. Code §
												1143.51 (relating to general
						payment policy); and 55 Pa. Code §
												1143.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › PAYMENT FOR PODIATRISTS' SERVICES › Section 1143.55 - Payment conditions for diagnostic services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for diagnostic X-ray services performed in
					 the podiatrist's office if the following requirements are met:
(1) The podiatrist examines the patient prior
				  to taking or ordering the X-ray.
(2) Initial and follow-up X-rays are taken on
				  the basis of medical justification which is documented in the medical
				  record.
(3) The X-rays are of
				  diagnostic quality and each film photographically records:
(i) The name of the patient.
(ii) The date of the X-ray.
(iii) A designation of right and
				  left.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › PAYMENT FOR PODIATRISTS' SERVICES › Section 1143.56 - Payment conditions for orthopedic shoes, molded shoes and shoe inserts

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made to enrolled medical suppliers in accordance
					 with the conditions and limitations specified in Chapter 1123 (relating to
					 medical supplies), for molded shoes, shoe inserts and, only if the recipient is
					 eligible and 20 years of age or younger, for orthopedic shoes.
This section cited in 55 Pa. Code §
												1143.51 (relating to general
						payment policy); and 55 Pa. Code §
												1143.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › PAYMENT FOR PODIATRISTS' SERVICES › Section 1143.57 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
The following limits apply to payment for compensable
					 services:
(1) Payment for office visit
				  for podiatric services is limited to the podiatrist's usual charge to the
				  general public, not to exceed the maximum allowable payment established in
				  Chapter 1150 (relating to MA Program payment policies) and the MA Program fee
				  schedule.
(2) Payment is made to
				  only one podiatrist for a particular service or procedure and services shall be
				  billed in the name of the podiatrist providing the service.
(3) Payment for X-rays taken in the
				  podiatrist's office during the course of a treatment is limited to the maximum
				  fee per limb specified in the MA Program fee schedule, in addition to the visit
				  fee.
This section cited in 55 Pa. Code §
												1143.51 (relating to general
						payment policy); and 55 Pa. Code §
												1143.52 (relating to payment
						conditions for various services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › PAYMENT FOR PODIATRISTS' SERVICES › Section 1143.58 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment is not made to a podiatrist for:
(1) Services and items not listed in the MA
				  Program fee schedule.
(2)
				  Fabricating or dispensing orthopedic shoes, shoe inserts and other supportive
				  devices for the feet.
(3) Casting
				  for shoe inserts.
(4) Medical
				  services or surgical procedures performed on an inpatient basis that could have
				  been performed in the podiatrist's office, the emergency room, or a short
				  procedure unit without endangering the life or health of the patient.
(5) Medical or surgical procedures designated
				  in the fee schedule in Chapter 1150 (relating to MA Program payment policies)
				  and the MA Program fee schedule as outpatient procedures, signified by the
				  letters OP, which are performed on an inpatient basis unless the requirements
				  specified in Chapter 1150 are met.
(6) Medical services or surgical procedures
				  performed on an inpatient basis if the Department denies payment to the
				  hospital for the days during which the podiatrist's care is rendered. The
				  podiatrist may not bill the recipient for the disallowed services.
(7) Services rendered in the emergency room
				  of a hospital if the recipient is admitted to the hospital as an inpatient on
				  the same day or the service is a nonemergency medical service.
(8) Treatment of flat foot.
(9) Treatment of subluxations of the
				  foot.
(10) Routine foot care,
				  including the cutting or removal of corns, callouses, the trimming of nails and
				  other routine hygienic care.
(11)
				  Physical therapy.
(12) Diagnostic
				  or therapeutic procedures for experimental, research or educational
				  purposes.
(13) Compensable
				  podiatrist's services if full payment as specified in §
											1101.62 (relating to maximum fees)
				  is available from another public agency or another insurance or health
				  program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1143 - PODIATRISTS' SERVICES › UTILIZATION CONTROL › Section 1143.71 - 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 1143 - PODIATRISTS' SERVICES › ADMINISTRATIVE SANCTIONS › Section 1143.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with this part, 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 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › GENERAL PROVISIONS › Section 1144.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific medically
					 necessary CRNP services rendered to eligible recipients by CRNPs enrolled as
					 providers under the program. Payment for CRNP services is subject to this
					 chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program
					 payment policies) and limitations established in the MA Program Fee
					 Schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › GENERAL PROVISIONS › Section 1144.2 - 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
-A registered nurse licensed in this Commonwealth who is
					 certified by the State Board of Nursing and State Board of Medicine in a
					 particular clinical specialty area who, while functioning in the expanded role
					 as a professional nurse, performs acts of medical diagnosis or prescription of
					 medical therapeutic or corrective measures in collaboration with and under the
					 direction of a physician licensed to practice medicine in this
					 Commonwealth.
CRNP services
-Care provided within the
					 scope of a CRNP professional practice and licensure.
Direction
-Physician supervision of the
					 CRNPs performance of medical acts as defined in 49 Pa. Code §
										21.251 (relating to
					 definitions).
Protocol
-The written treatment
					 instructions prepared by the supervising physician for use by the
					 CRNP.
This section cited in 55 Pa. Code §
												1144.42 (relating to ongoing
						responsibilities of providers).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › SCOPE OF BENEFITS › Section 1144.21 - 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 CRNP services compensable under the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › SCOPE OF BENEFITS › Section 1144.22 - 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 CRNP services compensable under the MA Program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › SCOPE OF BENEFITS › Section 1144.23 - 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 CRNP
					 services unless they are also either categorically or medically
					 needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › SCOPE OF BENEFITS › Section 1144.24 - 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 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › PROVIDER PARTICIPATION › Section 1144.41 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
Participation requirements are established in §§
					 1101.41-1101.43 (relating to participation).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › PROVIDER PARTICIPATION › Section 1144.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Ongoing responsibilities of providers are
				  established in Chapter 1101 (relating to general provisions).
(b) In addition, CRNPs shall furnish the
				  following to the Department:
(1) The identity
				  of the physician providing medical direction as defined in §
											1144.2 (relating to
				  definitions).
(2) The established
				  physician/CRNP protocols.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › PAYMENT FOR CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › Section 1144.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for compensable CRNP services provided by
					 participating CRNPs subject to the conditions and limitations established in
					 this chapter. Chapters 1101 and 1150 (relating to general provisions; and the
					 MA Program payment policies) and the MA Program Fee Schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › PAYMENT FOR CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › Section 1144.52 - Payment conditions

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will be made to a CRNP for services furnished if
					 the following conditions are met:
(1)
				  The CRNP, unless qualifying for the exception in paragraph (3), does not have a
				  financial arrangement to provide the services as an employe of or is not under
				  contract to an enrolled medical service provider or practitioner.
(2) The services billed to the Department are
				  furnished by the CRNP in collaboration with and under the direction of a
				  physician licensed to practice medicine in this Commonwealth.
(3) An exception to the payment condition in
				  paragraph (1) has been established for the CRNP employed by an enrolled MA
				  entity unable to be reimbursed for Early and Periodic Screening, Diagnosis and
				  Treatment (EPSDT) screens. In this case, the CRNP may enroll with the
				  Department, with the employer recognized as the payee.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › PAYMENT FOR CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › Section 1144.53 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for the following:
(1) Procedures not listed in the MA Program
				  fee schedule or precluded by Chapter 1150 (relating to the MA Program payment
				  policies).
(2) Services and
				  procedures furnished by the CRNP for which payment is made to an enrolled
				  medical service provider or practitioner.
(3) Services and procedures for which payment
				  is available through other public agencies or private insurance plans as
				  described in §
										1101.64 (relating to third-party
				  medical resources (TPR)).
(4) The
				  same service and procedure furnished to the same recipient by a CRNP and
				  physician, with whom the CRNP has protocols, on the same day.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › UTILIZATION CONTROL › Section 1144.71 - 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 1144 - CERTIFIED REGISTERED NURSE PRACTITIONER SERVICES › ADMINISTRATIVE SANCTIONS › Section 1144.81 - 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 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 1145 - CHIROPRACTORS' SERVICES › GENERAL PROVISIONS › Section 1145.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific chiropractors'
					 services rendered to eligible recipients by chiropractors enrolled as providers
					 under the program. Payment for chiropractors' 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 1145 - CHIROPRACTORS' SERVICES › COVERED AND NONCOVERED SERVICES › Section 1145.11 - Types of services covered

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program covers the following chiropractors' services
					 as specified in §§
										1145.21-1145.23 (relating to scope of
					 benefits):
(1) Evaluation by means of
				  examination of the patient.
(2)
				  Treatment by means of manual manipulation of the spine to adjust misaligned or
				  displaced vertabrae.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › COVERED AND NONCOVERED SERVICES › Section 1145.12 - Outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
Chiropractors' services are covered when rendered in the
					 chiropractors' office, the home of the patient or in a skilled nursing or
					 intermediate care facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › COVERED AND NONCOVERED SERVICES › Section 1145.13 - Inpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
Chiropractors' services are not covered when rendered in a
					 location in a hospital, including but not limited to a hospital emergency room,
					 a hospital short procedure unit or a hospital clinic.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › COVERED AND NONCOVERED SERVICES › Section 1145.14 - Noncovered services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for the following types of
					 services regardless of where or to whom they are provided:
(1) Treatment other than manual manipulation
				  of the spine to correct a subluxation.
(2) Physical therapy.
(3) Traction procedures.
(4) Physical examinations.
(5) Consultations.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › SCOPE OF BENEFITS › Section 1145.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for covered
					 chiropractors' services.
This section cited in 55 Pa. Code §
												1145.11 (relating to types of
						services covered).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › SCOPE OF BENEFITS › Section 1145.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for covered
					 chiropractors' services.
This section cited in 55 Pa. Code §
												1145.11 (relating to types of
						services covered).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › SCOPE OF BENEFITS › Section 1145.23 - 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
					 chiropractors' services provided in the office or home.
This section cited in 55 Pa. Code §
												1145.11 (relating to types of
						services covered).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › SCOPE OF BENEFITS › Section 1145.24 - 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 1145 - CHIROPRACTORS' SERVICES › PROVIDER PARTICIPATION › Section 1145.41 - 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), chiropractors are required,
					 as a condition of participation, to be licensed by the State Board of
					 Chiropractic Examiners or, for drugless therapy, by the State Board of
					 Medicine.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › PAYMENT FOR CHIROPRACTORS' SERVICES › Section 1145.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered services provided by
					 participating chiropractors subject to the conditions and limitations
					 established in this section, §
										1145.54 (relating to
					 noncompensable services), and Chapters 1101 and 1150 (relating to general
					 provisions; and MA Program payment policies) and the MA Program fee schedule.
					 Payment will not be made for compensable chiropractors' service if payment is
					 available from another public agency or insurance or health program.
					 Chiropractors' services shall be billed in the name of the chiropractor
					 providing the service.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › PAYMENT FOR CHIROPRACTORS' SERVICES › Section 1145.54 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made to a chiropractor for the
					 following:
(1) Orthotics.
(2) Prosthetics.
(3) Medical supplies.
(4) X-rays.
(5) Services not included in Chapter 1150
				  (relating to MA Program payment policies) and the MA Program fee schedule.
				  Payment will be made to approved medical suppliers for compensable items
				  ordered by a chiropractor.
This section cited in 55 Pa. Code §
												1145.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1145 - CHIROPRACTORS' SERVICES › UTILIZATION REVIEW › Section 1145.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims 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 1145 - CHIROPRACTORS' SERVICES › ADMINISTRATIVE SANCTIONS › Section 1145.81 - 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 chiropractic practice, or to have otherwise
					 violated the standard 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 1147 - OPTOMETRISTS' SERVICES › GENERAL PROVISIONS › Section 1147.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA program provides payment for specific optometric
					 services rendered to eligible recipients by optometrists enrolled as providers
					 under the program. Payment for optometric 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 1147 - OPTOMETRISTS' SERVICES › GENERAL PROVISIONS › Section 1147.2 - 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:
Adult
-A person 21 years of age or older
					 unless otherwise specified in Chapter 1150 (relating to MA Program payment
					 policies) and the MA Program Fee Schedule.
Child
-A person 20 years of age or younger
					 unless otherwise specified in Chapter 1150.
Eyeglasses
-A pair of untinted prescription
					 lenses and a frame.
State Board
-The State Board of
					 Optometry.
Vision examination
-An examination of the
					 eyes by a doctor of optometry or a physician skilled in diseases of the eye to
					 determine visual, muscular or neurological abnormalities, vision problems,
					 ocular disease or ocular manifestation of systemic disease, and the
					 prescription of lenses or referral for treatment. An examination rendered and
					 documented in the patient's record may include the following:
(i) Complete history.
(ii) Naked visual acuity.
(iii) Detailed report of the external
				  findings.
(iv) Opthalmoscopic
				  examination (media, fundus, blood vessels, disc.).
(v) Corneal curvature measurements
				  (dioptral).
(vi) Static
				  retinoscopy.
(vii) Amplitude of
				  convergence and accommodation.
(viii) Ocular muscle balance.
(ix) Subjective refraction test.
(x) Fusion.
(xi) Steroposis.
(xii) Color vision.
(xiii) Visual fields
				  (confrontation).
(xiv) Visual
				  fields, central (after age 40).
(xv) Prescription given and visual acuity
				  obtained.
(xvi) Biomicroscopy (slit
				  lamp).
(xvii) Tonometry.
(xviii) Prognosis, stable or
				  unstable.
This section cited in 55 Pa. Code §
												1147.11 (relating to types of
						services covered); and 55 Pa. Code §
												1147.53 (relating to limitations
						on payment).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › COVERED AND NONCOVERED SERVICES › Section 1147.11 - Types of services covered

Current through Register Vol. 54, No. 28, July 13, 2024
The MA program covers the following outpatient optometric
					 services and items as specified in §§
										1147.21-1147.23 (relating to scope of
					 benefits):
(1) Vision examinations as
				  defined in §
										1147.2 (relating to
				  definitions).
(2) The provision of
				  eyeglasses, eye prostheses, low vision aids, eyeglasses and other items as
				  described in the MA program fee schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › COVERED AND NONCOVERED SERVICES › Section 1147.12 - Outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
Outpatient optometric services are compensable when
					 provided in the optometrist's office, the office of another optometrist during
					 the other optometrist's temporary absence from practice, a hospital, a nursing
					 home or in the patient's home when the patient is physically incapable of
					 coming to the optometrist's office. Payment is subject to the conditions and
					 limitations established in §§
										1147.51,
					 1147.53 and
					 1147.54 (relating to general
					 payment policy; limitations on payment; and noncompensable services and items)
					 and 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 1147 - OPTOMETRISTS' SERVICES › COVERED AND NONCOVERED SERVICES › Section 1147.13 - Inpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
Inpatient optometric services are compensable. Payment is
					 subject to the conditions and limitations established in §§
										1147.51,
					 1147.53 and
					 1147.54 (relating to general
					 payment policy; limitations on payment; and noncompensable services and items),
					 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 1147 - OPTOMETRISTS' SERVICES › COVERED AND NONCOVERED SERVICES › Section 1147.14 - Noncovered services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for the following types of
					 services regardless of where or to whom they are provided:
(1) Orthoptic training.
(2) Services provided in practice locations,
				  other than those recognized by the State Board.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › SCOPE OF BENEFITS › Section 1147.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for vision
					 examinations, low vision aids and eye prostheses. They are not eligible for
					 eyeglasses unless they are 20 years of age or younger and the eyeglasses have
					 been:
(1) Prescribed through the EPSDT
				  program as described in §
										1101.32(a)(1)
				  (relating to coverage variations).
(2) Prescribed through the School Medical
				  program as described in § 1101.32(a)(2).
(3) Prior authorized by the Department as
				  provided through the EPSDT program when screening has not occurred under §
										1101.32(a)(1).
The provisions of this §
												1147.21 issued under sections
						403(a) and (b) and 443.6 of the Public Welfare Code (62 P. S. §§
													403(a) and (b) and
						443.6).
This section cited in 55 Pa. Code §
												1147.11 (relating to types of
						services covered).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › SCOPE OF BENEFITS › Section 1147.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for vision
					 examinations. They are not eligible for eyeglasses, low vision aids or
					 prostheses unless they are 20 years of age or younger and the eyeglasses, low
					 vision aids or prostheses have been:
(1) Prescribed through the EPSDT program as
				  described in §
										1101.32(a)(1)
				  (relating to coverage variations).
(2) Prescribed through the School Medical
				  program as described in § 1101.32(a)(2).
(3) Prior authorized by the Department as
				  provided through the EPSDT program when screening has not occurred under §
										1101.32(a)(1).
The provisions of this §
												1147.22 issued under sections
						403(a) and (b) and 443.6 of the Public Welfare Code (62 P. S. §§
													403(a) and (b) and
						443.6).
This section cited in 55 Pa. Code §
												1147.11 (relating to types of
						services covered).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › SCOPE OF BENEFITS › Section 1147.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are only eligible for vision
					 examinations. They are not eligible for eyeglasses, low vision aids or eye
					 prostheses. However, State Blind Pension recipients are eligible for eye
					 prostheses if they are also categorically needy.
This section cited in 55 Pa. Code §
												1147.11 (relating to types of
						services covered).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › SCOPE OF BENEFITS › Section 1147.24 - 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 1147 - OPTOMETRISTS' SERVICES › PROVIDER PARTICIPATION › Section 1147.41 - 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), optometrists are required, as
					 a condition of participation, to have the offices in which they practice
					 registered with the State Board.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › PAYMENT FOR OPTOMETRIC SERVICES › Section 1147.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for covered services provided by
					 participating optometrists subject to the conditions and limitations
					 established in this section and §§
										1147.53 and
					 1147.54 (relating to limitations
					 on payment; and noncompensable services and items), and Chapters 1101 and 1150
					 (relating to general provisions; and MA Program payment policies) and the MA
					 Program fee schedule. Payment will not be made for a compensable optometric
					 service if payment is available from another public agency or another insurance
					 or health program. Optometric services shall be billed in the name of the
					 optometrist providing the service.
This section cited in 55 Pa. Code §
												1147.12 (relating to outpatient
						services); and 55 Pa. Code §
												1147.13 (relating to inpatient
						services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › PAYMENT FOR OPTOMETRIC SERVICES › Section 1147.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  vision examination is compensable only at the fee established in the MA Program
				  fee schedule regardless of whether the optional components described in §
										1147.2 (relating to definitions)
				  are provided.
(b) Eyeglasses are
				  limited to one full pair or two lenses per year. These are compensable only for
				  eligible recipients who have received prior authorization from the Department
				  or are receiving the eyeglasses under the EPSDT program or the School Medical
				  program as described in Chapter 1101 (relating to general
				  provisions).
(c) Low vision aids
				  are limited to one per recipient per 2 years.
(d) Eye prostheses are limited to one per
				  recipient per 2 years. These are compensable only for categorically needy
				  recipients.
(e) Contact lenses are
				  only compensable when used as a prostheses, such as, to replace the lens of the
				  eye.
(f) Optometric services are
				  compensable when provided in a clinic. The clinic is considered the provider
				  and is responsible for billing the Department for services as defined in §
										1221.51(5) 
				  (relating to general payment policy).
The provisions of this §
												1147.53 issued under sections
						403(a) and (b) and 443.6 of the Public Welfare Code (62 P. S. §§
													403(a) and (b) and
						443.6).
This section cited in 55 Pa. Code §
												1147.12 (relating to outpatient
						services); 55 Pa. Code §
												1147.13 (relating to inpatient
						services); and 55 Pa. Code §
												1147.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › PAYMENT FOR OPTOMETRIC SERVICES › Section 1147.54 - 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) Eyeglasses for individuals
				  21 years of age or older.
(2)
				  Prescription sunglasses.
(3) Tinted
				  lenses.
(4) Orthoptic
				  training.
(5) Items and services
				  not listed as compensable in MA program fee schedule.
This section cited in 55 Pa. Code §
												1147.12 (relating to outpatient
						services); 55 Pa. Code §
												1147.13 (relating to inpatient
						services); and 55 Pa. Code §
												1147.51 (relating to general
						payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1147 - OPTOMETRISTS' SERVICES › UTILIZATION REVIEW › Section 1147.71 - 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 1147 - OPTOMETRISTS' SERVICES › ADMINISTRATIVE SANCTIONS › Section 1147.81 - 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 optometric 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 1149 - DENTISTS' SERVICES › GENERAL PROVISIONS › Section 1149.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The Medical Assistance Program provides payment for
					 dentists' services rendered to eligible recipients by dentists enrolled as
					 providers under the MA Program. Payment for dentists' 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 1149 - DENTISTS' SERVICES › GENERAL PROVISIONS › Section 1149.2 - 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:
Approved institution
-A university, college
					 or hospital whose dental school program is approved by the American Dental
					 Association or a Canadian university whose dental school program is recognized
					 by the American Dental Association.
Board certified or Board eligible
					 orthodontist
-A dentist who has successfully completed the full
					 curriculum of advanced education in orthodontics at an approved institution or
					 an orthodontic hospital residency program which is accredited by the Commission
					 on Accreditation of Dental and Dental Auxiliary Education Programs of the
					 American Dental Association.
Dental laboratory
-A laboratory, comprised
					 of dental technicians, and engaged in the business of constructing, altering,
					 repairing or duplicating dentures, plates, partial plates, bridges, splints and
					 orthodontic or prosthetic appliances.
Dental technician
-An individual not
					 licensed to practice dentistry in this Commonwealth but engaged in the business
					 of constructing, altering, repairing or duplicating dentures, plates, partial
					 plates, bridges, splints and orthodontic or prosthetic appliances from a
					 prescription by a dentist.
Dentist
-An individual licensed under the
					 laws of the Commonwealth to practice dentistry within the scope of The Dental
					 Law (63 P. S. §§
											120-130g).
Oral and maxillofacial surgeon
-A dentist
					 who limits his practice to the part of dental care which deals with the
					 diagnosis, the surgical and adjunctive treatment of diseases, injuries and
					 defects of the oral and maxillofacial region.
Pedodontist
-A dentist who limits his
					 practice to the diagnosis and treatment of conditions of the teeth and mouth in
					 children.
The provisions of this §
												1149.2 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).
This section cited in 55 Pa. Code §
												1149.43 (relating to requirements
						for dental records); and 55 Pa. Code §
												1149.55 (relating to payment
						conditions for orthodontic
						services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › SCOPE OF BENEFITS › Section 1149.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy adult recipients are eligible for all
					 medically necessary dental services, subject to the conditions and limitations
					 established in this chapter, Chapters 1101 and 1150 (relating to general
					 provisions; and MA Program payment policies) and the MA Program fee schedule.
					 Categorically needy recipients under 21 years of age are eligible for all
					 medically necessary dental services.
The provisions of this §
												1149.21 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).
This section cited in 55 Pa. Code §
												1149.57 (relating to
						noncompensable services and items).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › SCOPE OF BENEFITS › Section 1149.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy adult recipients are eligible for medically
					 necessary dental services only when provided in an inpatient, ambulatory
					 surgical center, or short procedure unit setting, and subject to the conditions
					 and limitations established in this chapter and Chapters 1101 and 1150
					 (relating to general provisions; and MA Program payment policies) and the MA
					 Program fee schedule. Medically needy recipients under 21 years of age are
					 eligible for all medically necessary dental services.
The provisions of this §
												1149.22 amended under sections
						201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code
						(62
						P. S. §§
													201(2),
						403(b), 443.1, 443.3, 443.6,
						448 and 454).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › SCOPE OF BENEFITS › Section 1149.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except as noted in subsection (b), State
				  Blind Pension recipients are eligible for all medically necessary dental
				  services, subject to the conditions and limitations established in this
				  chapter, Chapters 1101 and 1150 (relating to the general provisions; and MA
				  Program payment policies) and the MA Program fee schedule.
(b) State Blind Pension recipients are not
				  eligible for radiological services or inpatient dental services. State Blind
				  Pension recipients are eligible for radiological services and inpatient
				  surgical procedures and emergency dental services if they qualify as
				  categorically needy or medically needy recipients.
The provisions of this §
												1149.23 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 1149 - DENTISTS' SERVICES › SCOPE OF BENEFITS › Section 1149.24 - Scope of benefits for GA recipients

Current through Register Vol. 54, No. 28, July 13, 2024
(a) GA chronically needy and nonmoney payment
				  recipients, age 21 to 65, are eligible for medically necessary dental services
				  subject to the conditions and limitations established in this chapter, Chapters
				  1101 and 1150 (relating to general provisions; and MA Program payment policies)
				  and the MA Program fee schedule.
(b) GA medically needy only recipients, age
				  21 to 65, are eligible for medically necessary dental services only when
				  provided in an inpatient, ambulatory surgical center, or short procedure unit
				  setting, and subject to the conditions and limitations established in this
				  chapter and Chapters 1101 and 1150 (relating to general provisions; and MA
				  Program payment policies) and the MA Program fee schedule.
The provisions of this §
												1149.24 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 1149 - DENTISTS' SERVICES › PROVIDER PARTICIPATION › Section 1149.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the ongoing responsibilities established in
					 §
										1101.51 (relating to ongoing
					 responsibilities of providers), dentists shall:
(1) Establish and maintain dental records in
				  accordance with §
										1149.43 (relating to requirements
				  for dental records).
(2) Submit to
				  the Department upon request copies of dental records, as described in §
										1149.43.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1149 - DENTISTS' SERVICES › PROVIDER PARTICIPATION › Section 1149.43 - Requirements for dental records

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the recordkeeping requirements set forth in
					 Chapter 1101 (relating to general provisions), dentists shall maintain a dental
					 record for each MA recipient in accordance with the following requirements:
(1) The record shall contain a tooth
				  chart indicating the condition of the patient's teeth as observed on the
				  initial oral examination. The dentist shall clearly indicate on the tooth
				  chart:
(i) Missing permanent teeth.
(ii) Permanent teeth to be
				  extracted.
(iii) Teeth to be
				  restored by surface.