Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › GENERAL PROVISIONS › Section 1141.2 - 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:
Abortion
-The deliberate termination of a
					 pregnancy before the fetus is viable.
Chronic condition
-An illness which
					 frequently recurs or persists for a period in excess of 3 months.
Consultation
-A medical evaluation
					 conducted by a specialist at the request of the attending practitioner. For the
					 purposes of the Medical Assistance Program a consultation shall include taking
					 a medical history, examining the patient and preparing a written report that is
					 incorporated into the record of the patient.
Cosmetic surgery
-A surgical procedure the
					 primary purpose of which is to improve the appearance of the patient. The
					 procedures include, but are not limited to, otoplasty for protruding ears or
					 lop ears, rhinoplasty, except to correct internal nasal deformity, nasal
					 reconstruction, excision of keloids, fascioplasty, osteoplasty for prognathism
					 or micrognathism or both, dermabrasion, skin grafts and lipectomy.
Covered services
-A benefit to which a
					 Medical Assistance recipient is entitled under the Medical Assistance
					 program.
Emergency situation
-A condition in which
					 immediate medical care is necessary to prevent the death or serious impairment
					 of health of the individual.
Experimental procedure
-A procedure that
					 deviates from customary standards of medical practice, is not routinely used in
					 the medical or surgical treatment of a specific illness or condition, or is not
					 of proven medical value.
Family planning services
-Those diagnostic
					 services, treatments, drugs, supplies, devices and counseling services
					 furnished to individuals to enable them to control the number and spacing of
					 their children.
General medical examination
-A medical
					 evaluation conducted by the attending physician of the patient, whether a
					 general practitioner or specialist, at the request of the patient. The
					 evaluation shall consist of a physical examination, the evaluation of
					 diagnostic studies, if warranted, and the recording of the findings in the
					 medical file of the patient.
Institutionalized individual
-A person who
					 is one of the following:
(i)
				  Involuntarily detained under a civil or criminal statute in a correctional,
				  rehabilitative or mental retardation facility including a psychiatric hospital
				  or other facility for the care and treatment of mental illness or mental
				  retardation.
(ii) Confined under
				  voluntary commitment in a psychiatric hospital, mental retardation facility or
				  other facility for the care and treatment of mental illness or mental
				  retardation.
Medical emergency care
-Care rendered in
					 response to the sudden and unexpected onset of a medical, not surgical
					 condition, requiring medical, not surgical, intervention which the recipient
					 secures immediately after the onset or as soon thereafter as the care can be
					 made available, but in no case later than 72 hours after the onset. In order to
					 determine whether a medical emergency existed the following criteria shall be
					 applied:
(i) Severe symptoms have to
				  occur. The symptoms must be sufficiently severe to cause a person to seek
				  immediate medical aid. Some symptoms or conditions indicating medical emergency
				  care are listed in Appendix C.
(ii)
				  Severe symptoms must occur suddenly and unexpectedly. Subacute symptoms of a
				  chronic condition would not qualify as a medical emergency. However, chronic
				  symptoms that suddenly become severe enough to require immediate medical
				  attention would qualify.
(iii)
				  Immediate care was secured. A medical emergency would not be considered to
				  exist if medical care were not rendered immediately after the patient reported
				  his symptoms to the physician. A telephone call to a doctor would not fulfill
				  this requirement if examination and treatment by the physician were deferred
				  until the next day.
Medical examination requested by the
					 Department
-A medical evaluation conducted by the attending physician
					 of the patient whether a general practitioner or specialist at the request of
					 the Department. The evaluation shall consist of a physical examination, the
					 evaluation of diagnostic studies, the recording of findings in the file of the
					 patient and the completion of medical evaluation forms supplied by the
					 Department.
Medical justification
-Written
					 documentation in the medical record of the patient indicating the specific
					 health condition or risk that made the particular service the physician
					 rendered, ordered or prescribed necessary.
Medically necessary
-A service, item,
					 procedure or level of care that is:
(i) Compensable under the Medical Assistance
				  program.
(ii) Necessary to the
				  proper treatment or management of an illness, injury or disability.
(iii) Prescribed, provided or ordered by an
				  appropriate licensed practitioner in accordance with accepted standards of
				  practice.
Mentally incompetent individual
-A person
					 who has been declared mentally incompetent by a Federal, State or local court
					 of competent jurisdiction for any purpose unless he has been declared competent
					 for the purposes which include the ability to consent to sterilization.
Noncompensable
-A service a provider
					 furnishes for which there is no provision for payment under Medical Assistance
					 regulations.
Nonemergency medical services
-A
					 compensable physicians' services other than those provided for condition
					 urgently requiring medical intervention in order to sustain the life of the
					 person to prevent damage to his health.
Physician
-An individual licensed under the
					 laws of this Commonwealth to practice medicine and surgery within the scope of
					 the Medical Practice Act of July 20, 1974 (P. L. 551, No. 190) (63 P. S. §
											421.10) or the Osteopathic Medical Practice
					 Act (63 P. S. §§
											271.1-271.18).
Short procedure unit
-A unit of a hospital
					 organized for the delivery of nonemergency surgical services to patients who do
					 not remain in the hospital overnight.
Specialist
-A physician who limits his
					 practice to the study and treatment of one class of diseases or to treatment of
					 specific organs or systems within the body, recognized by the American Medical
					 Association or the American Osteopathic Association for his particular
					 specialty.
Sterilization
-A recognized medical
					 procedure the primary purpose of which is to render the patient incapable of
					 reproduction.
This section cited in 55 Pa. Code §
												1141.55 (relating to payment
						conditions for sterilizations); and 55 Pa. Code §
												1141.59 (relating to
						noncompensable services).