Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 6142 (September 30, 2023).

55 Pa. Code § 1221.43. Participation requirements for hospital clinics and emergency rooms for higher reimbursement rate.

§ 1221.43. Participation requirements for hospital clinics and emergency rooms for higher reimbursement rate.

 To be eligible to bill for the higher MA fee identified in Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule outpatient hospital clinics and emergency rooms shall:

   (1)  Provide comprehensive medical services for a minimum of 40 hours per week. Outpatient hospital clinics meet this requirement if the outpatient department of the hospital is open and provides some clinic service 40 hours per week.

   (2)  Have a licensed physician present in the clinic or emergency room at all times during scheduled hours of operation to perform medical services. A physician shall be responsible for the overall management of patient care.

   (3)  Be approved by the Department for higher reimbursement rate.


   The provisions of this §  1221.43 issued under section 443.3(1) of the Public Welfare Code (62 P. S. §  443.3(1)).


   The provisions of this §  1221.43 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; amended through December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (86853) to (86854).

Cross References

   This section cited in 55 Pa. Code §  1221.45 (relating to additional participation requirements for medical school clinics).

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