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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 2336 (April 27, 2024).

55 Pa. Code § 1101.21. Definitions.


§ 1101.21. Definitions.

 The following words and terms, when used in this part, have the following meanings, unless the context clearly indicates otherwise:

   Adult—An MA recipient 21 years of age or older.

   CRNP—Certified registered nurse practitioner.

   Categorically needy—Aged, blind or disabled individuals or families and children who are otherwise eligible for Medicaid and who meet the financial eligibility requirements for TANF, SSI or an optional State supplement.

   Complete medical history—A chronological medical record which includes, but is not limited to, major complaints, present medical history, past medical history, family history and social history.

   County Assistance Offices or CAOs—The local offices of the Department that administer the MA Program on the local level. They determine recipient eligibility and perform other necessary MA functions such as prior authorization and client referral to a source of medical services.

   Covered service—A benefit to which a MA recipient is entitled under the MA Program of the Commonwealth.

   Department—The Department of Human Services of the Commonwealth or a subagency thereof.

   Emergency situation—A condition in which immediate medical care is necessary to prevent the death or serious impairment of health of the individual.

   Enroll—The act of becoming eligible to participate in the MA Program by completing the provider enrollment form, entering into or renewing as required a written provider agreement and meeting other participation requirements specified in this chapter and the appropriate separate chapters relating to each provider type.

   EPSDT—Early and Periodic Screening, Diagnosis and Treatment Program.

   FQHC—Federally qualified health center.

   Factor—An individual or an organization, such as a service bureau, that advances money to a provider for accounts receivable that the provider has assigned, sold or transferred to the individual or organization for an added fee or a deduction of a portion of the accounts receivable.

   GA—General Assistance—MA funded solely by State funds as authorized under Article IV of the Public Welfare Code (62 P. S. § §  401—488).

   General public—Payors other than Medicaid. The term includes other health insurance plans.

   HHS—The United States Department of Health and Human Services or its successor agency, which is given responsibility for implementation of Title XIX of the Social Security Act.

   MA—Medical Assistance.

   Medicaid—Medical Assistance provided under a State Plan approved by HHS under Title XIX of the Social Security Act.

   Medical facility—A licensed or approved hospital, skilled nursing facility, intermediate care facility, intermediate care facility for the mentally retarded, public clinic, shared health facility, rural health clinic, psychiatric clinic, pharmacy, laboratory, drug and alcohol clinic, partial hospitalization facility or family planning clinic.

   Medically necessary—A service, item, procedure or level of care that is:

     (i)   Compensable under the MA 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.

   Medically needy—A term used to refer to aged, blind or disabled individuals or families and children who are otherwise eligible for Medicaid and whose income and resources are above the limits prescribed for the categorically needy but are within limits set under the Medicaid State Plan.

   Noncompensable item—A service or supply a provider furnishes for which there is no provision for payment under this part.

   Parent/caretaker—The person responsible for the care and control of an unemancipated minor child. This includes mother or father, grandmother or grandfather, stepmother or stepfather or another relative related by blood or marriage.

   Postpartum period—The period beginning on the last day of the pregnancy and extending through the end of the month in which the 60-day period following termination of the pregnancy ends.

   Practitioner—A medical doctor, doctor of osteopathy, dentist, optometrist, podiatrist, chiropractor or other medical professional licensed by the Commonwealth or by another state who is authorized to participate in the MA Program as a provider.

   Prepayment review—Determination of the medical necessity of a service or item before payment is made to the provider. Prepayment review is performed after the service or item is provided and involves an examination of an invoice and related material, when appropriate. Prepayment review is not prior authorization.

   Prior authorization—A procedure specifically required or authorized by this title wherein the delivery of an MA item or service is either conditioned upon or delayed by a prior determination by the Department or its agents or employees that an eligible MA recipient is eligible for a particular item or service or that there is medical necessity for a particular item or service or that a particular item or service is suitable to a particular recipient.

   Professional Standards Review Organization or PSRO—An organization which HHS has charged with the responsibility for operating professional review systems to determine whether hospital services are medically necessary, provided appropriately, carried out on a timely basis and meet professional standards.

   Program—The MA program of the Commonwealth.

   Provider—An individual or medical facility which signs an agreement with the Department to participate in the MA program, including, but not limited to: licensed practitioners, pharmacies, hospitals, nursing homes, clinics, home health agencies and medical purveyors.

   Public clinic—A health clinic operated by a Federal, State or local governmental agency.

   Purveyor—A person other than a practitioner who, directly or indirectly, engages in the business of supplying to patients medical supplies, equipment or services for which reimbursement under the MA program is received, including, but not limited to: clinical laboratory services or supplies, X-ray laboratory services or supplies, inhalation therapy services or equipment, ambulance services, sick room supplies, physical therapy services or equipment, and orthopedic or surgical appliances or supplies.

   Recipient—A person or family that is eligible for MA benefits.

   School child—A child attending a kindergarten, elementary, grade or high school, either public or private.

   Shared health facility—An entity other than a licensed or approved hospital facility, skilled nursing facility, intermediate care facility, intermediate care facility for the mentally retarded, rural health clinic, public clinic or Health Maintenance Organization in which:

     (i)   Medical services, either alone or together with support services, are provided at a single location.

     (ii)   Services are provided by three or more practitioners, two or more of whom are practicing within different professions.

     (iii)   Practitioners share any of the following: common waiting areas, examining rooms, equipment, supporting staff or records.

     (iv)   At least one practitioner receives payment on a fee for service basis.

     (v)   A provider receiving more than $30,000 in payment from the MA Program during the 12-month period prior to the date of the initial or renewal application of the shared health facility for registration in the MA Program.

   State Blind Pension recipient—An individual 21 years of age or older who by virtue of meeting the requirements of Article V of the Public Welfare Code (62 P. S. § §  501—515) is eligible for pension payments and payments made on his behalf for medical or other health care, with the exception of inpatient hospital care and post-hospital care in the home provided by a hospital. Payment for medical and health care is made solely from Commonwealth funds since these individuals do not meet the criteria for Federal funding of their medical care under Medicaid.


   The provisions of this §  1101.21 amended under sections 201(2), 403(b), 443.1, 443.3, 443.4, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.4, 443.6, 448 and 454).


   The provisions of this §  1101.21 amended through April 27, 1984, effective April 28, 1984, 14 Pa.B. 1454; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended August 5, 2005, effective August 10, 2005, 35 Pa.B. 4309; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811. Immediately preceding text appears at serial pages (266131) to (266132) and (286983) to (286984).

Cross References

   This section cited in 55 Pa. Code §  140.721 (relating to conditions of eligibility); 55 Pa. Code §  1101.31 (relating to scope); 55 Pa. Code §  1101.63 (relating to payment in full); 55 Pa. Code §  1187.11 (relating to scope of benefits for the categorically needy); 55 Pa. Code §  1187.12 (relating to scope of benefits for the medically needy); and 55 Pa. Code §  1187.152 (relating to additional reimbursement of nursing facility services related to exceptional DME).

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