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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 § 1221.51. General payment policy.


§ 1221.51. General payment policy.

 Payment for clinic and emergency room services is subject to the conditions and limitations in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program Fee Schedule. The following describes the payment policies applicable to hospital outpatient clinics, medical school clinics, independent medical clinics and hospital emergency rooms.

   (1)  Hospital outpatient clinics, medical school clinics and independent medical clinics have the option of billing either the fee for a specific compensable procedure performed in the clinic or, but not in addition to, the flat visit fee except as noted in paragraph (7). Compensable procedures are specified in the MA Program Fee Schedule. The visit fee includes the professional, technical and support components of a clinic visit. The visit fee includes medical services rendered by a physician or under the supervision of a physician, drugs and biologicals administered or provided during the clinic visit and services and supplies commonly rendered without charge and incident to professional services. Visit fees are listed in the MA Program Fee Schedule. Specific vaccines, as determined by the Department, and listed in Chapter 1241, Appendix D (relating to EPSDT immunization guidelines—statement of policy) are excluded from the established clinic fee and may be billed separately by clinics approved by the Department.

   (2)  Reimbursement for abortions performed in a clinic meeting the conditions set forth in §  1221.57 (relating to payment conditions for necessary abortions) is made on a component basis as listed in the MA Program Fee Schedule.

   (3)  The usual and customary charge to the general public for independent clinics with fee schedules based on the ability of the patient to pay shall be the most frequent charge to the self-paying public for the same service in the preceding calendar month.

   (4)  Hospital emergency rooms are paid a support component and a physicians component as set forth in Chapter 1150. Diagnostic and radiology services are compensable in addition to the physicians component as specified in paragraph (7).

   (5)  The hospital is considered the provider regardless of whether the hospital clinics are operated directly by the hospital or through contract between the hospital and other organizations or individuals. The hospital is responsible for the delivery of service and for billings.

   (6)  The medical school is considered the provider for all services provided by medical school clinics and is responsible for the delivery of the service and for billings.

   (7)  Diagnostic medical services, such as electrocardiograms, electroencephalograms, electromyographies and diagnostic or therapeutic radiology services provided during routine examination and treatment services are compensable in addition to the flat visit fee or fee for a specific compensable procedure. Endoscopic procedures, such as rhinoscopy, otoscopy or indirect laryngoscopy performed in the course of the visit are not compensable in addition to the flat visit fee.

   (8)  When two or more surgical operations are performed at the same time, or during the same visit, the procedure carrying the highest fee will be paid in full, plus 25% of the fee for the next highest procedure, with no allowance for additional procedures. The total fee allowance may not exceed $200.


   The provisions of this §  1221.51 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended January 24, 1992, effective November 9, 1991, 22 Pa.B. 361. Immediately preceding text appears at serial pages (131082) and (150219).

Cross References

   This section cited in 55 Pa. Code §  1147.53 (relating to limitations on payment); 55 Pa. Code §  1221.58 (relating to limitations on payment); and 55 Pa. Code §  1221.59 (relating to noncompensable services and items).

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