Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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55 Pa. Code § 1221.81. Provider misutilization.

ADMINISTRATIVE SANCTIONS


§ 1221.81. Provider misutilization.

 Providers determined to have billed for services inconsistent with MA Program regulations, to have provided services outside the scope of customary standards of medical practice, or to have otherwise violated the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1221.81 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599.

APPENDIX A
MEDICAL EMERGENCY
CARE SYMPTOMS


Allergy Reactions, Acute  (Except Allergy Tests)Glaucoma, Severe Headache, Severe
Appendicitis, AcuteHeart Attack, Suspected
Asthma, AcuteHemorrhage
Breathing Difficulties or Shortness of BreathHysteria Insulin Shock (Overdose)
Bronchitis, SevereKidney Stones
Bursitis, Severe OnsetMaternity Complications, such
Chest Pain, Severe as Suspected Miscarriage
ChokingPain, Sudden or Severe Onset
ColitisPleurisy
ComaPneumonitis
Convulsions and/or SeizuresPoisoning (including overdose)
CystitisPyelitis
Dermatitis or Hives (Resulting from Internal or Unknown Causes)Pyelonephritis (Shock) Spasms, Cerebral or Cardiac Spontaneous Pneumothorax
Diabetic ComaStomach Pains, Severe
Diarrhea, SevereStrangulated Hernia
Drug ReactionStroke
Earache, SevereSunstroke
Epistaxis (nosebleed)Swollen Ring Finger
FaintingTachycardia
Fecal Impaction, SevereThrombosis and/or Phlebitis
Food PoisoningUnconsciousness
Frost BiteUrinary Retention, Acute
Gall Bladder, Acute AttackVision loss, Sudden Onset
GastritisVomiting, Severe
Gastro-intestinal Conditions Acute



Source

   The provisions of this Appendix A adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (79331).

APPENDIX B. [Reserved]



Source

   The provisions of this Appendix B adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; amended August 7, 1981, effective August 8, 1981, 11 Pa.B. 2770; reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial pages (79331) to (79332).

APPENDIX C. [Reserved]



Source

   The provisions of this Appendix C adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial pages (79332) and (60960).

APPENDIX D. [Reserved]



Source

   The provisions of this Appendix D adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; amended February 13, 1981, effective February 15, 1981, 11 Pa.B. 657; reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial pages (60960) to (60965).



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