Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 8238 (December 30, 2023).

55 Pa. Code § 1221.59. Noncompensable services and items.

§ 1221.59. Noncompensable services and items.

 Payment will not be made to clinics or emergency rooms for the following services or items:

   (1)  Services rendered in the hospital emergency room to a recipient who is admitted to the hospital the same day.

   (2)  Services and procedures that are available through other public agencies or private insurance plans.

   (3)  Physicians’ services not listed in the MA Program Fee Schedule.

   (4)  Methadone maintenance.

   (5)  Prescribed medications and medical supplies. Payment for these services is made only to participating pharmacies and medical suppliers. Section 1221.51(1) (relating to general payment policy) describes an exception for specific vaccines provided in hospital outpatient clinics, if the hospital does not have a pharmacy enrolled in the MA Program, and independent medical/surgical clinics.

   (6)  Laboratory services. Payment for these services will be made only to participating laboratories.

   (7)  Surgical procedures and medical care provided in connection with sex reassignment. This includes, hormone therapy and release of vaginal adhesions.

   (8)  More than one flat visit fee or fee for a specific compensable service provided by an independent medical clinic, hospital outpatient department, medical school outpatient department or hospital emergency room on the same day, regardless of specialty, except as noted in §  1221.51(6) and (7).

   (9)  Nonemergency use of the emergency room. Services to patients who do not exhibit symptoms or have a diagnosis that is listed in Appendix A are not reimbursable unless the recipient declares that he does not have access to a primary care physician or an outpatient clinic to treat nonemergency situations. The hospital emergency room staff and the emergency room physician shall document in the patient’s medical record the declaration of no access to primary care.

Authority

   The provisions of this §  1221.59 amended under sections 201(2) and 443.3 of the Public Welfare Code (62 P. S. § §  201(2) and 443.3).

Source

   The provisions of this §  1221.59 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; amended September 22, 1995, effective September 23, 1995, 25 Pa.B. 3983. Immediately preceding text appears at serial pages (166155) to (166156).



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