Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › COVERED AND NONCOVERED SERVICES › Section 1153.14 - 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:
(
Editor's Note
: Under section 2(1) of the
					 act of October 28, 2022 (P.L. 1632, No. 98), §
										1153.14(1) is
					 abrogated.)
(1) A covered psychiatric
				  outpatient clinic, MMHT or partial hospitalization outpatient service conducted
				  over the telephone.
(2) Cancelled
				  appointments.
(3) Covered services
				  that have not been rendered.
(4) An
				  MA covered service, including psychiatric outpatient clinic, MMHT and partial
				  hospitalization outpatient services, provided to inmates of State or county
				  correctional institutions or committed residents of public
				  institutions.
(5) Psychiatric
				  outpatient clinic, MMHT or partial hospitalization outpatient services to
				  residents of treatment institutions, such as individuals who are also being
				  provided with room or board, or both, and services, on a 24-hour-a-day basis by
				  the same facility or distinct part of a facility or program.
(6) Services delivered at locations other
				  than licensed psychiatric outpatient clinics with the exception of MMHT under
				  the conditions specified in §
										1153.52(d)
				  (relating to payment conditions for various services) or partial
				  hospitalization outpatient facilities.
(7) Vocational rehabilitation, occupational
				  or recreational therapy, referral, information or education services, case
				  management, central intake or records, training, administration, program
				  evaluation, research or social services provided in psychiatric outpatient
				  clinics.
(8) Case management,
				  central intake or records, training, administration, social rehabilitation,
				  program evaluation or research provided in psychiatric outpatient partial
				  hospitalization facilities.
(9)
				  Psychiatric outpatient clinic services, MMHT services and psychiatric partial
				  hospitalization outpatient services provided on the same day to the same
				  individual, with the exception of clinical services not offered by the facility
				  providing services to the individual.
(10) Covered psychiatric outpatient clinic
				  services, MMHT services and psychiatric partial hospitalization outpatient
				  services, with the exception of family psychotherapy, provided to persons
				  without a mental diagnosis rendered by a psychiatrist in accordance with the
				  current version of the
Diagnostic and Statistical Manual of Mental
				  Disorders
or the
International Classification of
				  Diseases
-Chapter V, "Mental, Behavioral, and Neurodevelopmental
				  Disorders."
(11) Psychiatric
				  outpatient clinic, MMHT and psychiatric partial hospitalization outpatient
				  services provided to individuals with substance-related and addictive
				  disorders, unless the individual has a primary diagnosis of a mental illness or
				  emotional disturbance.
(12) Drugs,
				  biologicals and supplies furnished to an individual receiving services at a
				  psychiatric outpatient clinic or a partial hospitalization outpatient facility
				  during a visit to the psychiatric outpatient clinic or partial hospitalization
				  outpatient facility. These are included in the psychiatric outpatient clinic
				  medication visit fee or partial hospitalization session payment. Separate
				  billings from any source for items and services provided by the psychiatric
				  outpatient clinic are noncompensable.
(13) Services not specifically included in
				  the MA Program Fee Schedule are noncompensable.
(14) MMHT services not provided in accordance
				  with the conditions specified in § 1153.52(d).
(15) Services provided beyond the 30th
				  calendar day following intake, without review and approval of the initial
				  assessment and treatment plan in accordance with § 1153.52(a)(7) and
				  (8).
(16) The hours that the
				  individual participates in an education program delivered in the same setting
				  as a children and youth partial hospitalization outpatient program unless, in
				  addition to the teacher, a clinical staff person works with the child in the
				  classroom. The Department will reimburse for only that time during which the
				  individual is in direct contact with a clinical staff person.
(17) Group psychotherapy provided in the
				  individual's home.
(18) Psychiatric
				  outpatient clinic and partial hospitalization outpatient services provided to
				  nursing home residents on the grounds of the nursing home or under the
				  corporate umbrella of the nursing home.
(19) Electroconvulsive therapy and
				  electroencephalogram provided through MMHT.
(20) MMHT services provided on the same day
				  as other home and community-based behavioral health services to the same
				  individual with the exception of clinical services not offered by the
				  psychiatric outpatient clinic.
The provisions of this §
												1153.14 amended under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).