Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 51 Pa.B. 6384 (October 2, 2021).

55 Pa. Code § 1223.14. Noncovered services.

§ 1223.14. Noncovered services.

 Payment will not be made for the following types of services regardless of where or to whom they are provided:

   (1)  Nonmedical counseling consisting of supportive activities to improve an individual’s problem-solving and coping skills and intrapersonal or interpersonal development and functioning; and group recreation or group social activities, as group psychotherapy.

   (2)  Clinic visits, psychotherapy, diagnostic psychological evaluations, psychiatric evaluations and comprehensive medical evaluations conducted over the telephone, that is, any clinic service conducted over the telephone.

   (3)  Cancelled appointments.

   (4)  Covered services that have not been rendered.

   (5)  Inpatient hospital methadone maintenance.

   (6)  Vocational rehabilitation; day care; drug/alcohol or mental health partial hospitalization; reentry programs, occupational or recreational therapy; Driving While Intoxicated (DWI) or Driving Under the Influence Programs or Schools; referral, information or education services; experimental services; training; administration; follow-up or aftercare; program evaluation; case management; central intake or records; shelter services; research; drop-in, hot-line or social services; inpatient nonhospital or occupational program services, or any other service or program not specifically identified as a covered service in Chapter 1150 (relating to Medical Assistance Program payment policies) and the Medical Assistance (MA) Program fee schedule.

   (7)  An MA covered service, including drug/alcohol clinic services, provided to inmates of State or county correctional institutions or committed residents of public institutions.

   (8)  Drug/alcohol outpatient clinic services provided to residents of treatment institutions, that is, persons who are also being provided with room and board and services on a 24-hour basis by the same facility or distinct part of the facility or program. Drug/alcohol outpatient clinic services provided to residents of inpatient nonhospital and shelter facilities.

   (9)  Drug/alcohol outpatient clinic services provided to patients receiving psychiatric partial hospitalization services under the MA Program or drug/alcohol partial hospitalization services under the Department of Health.

   (10)  Covered drug/alcohol clinic services, with the exception of family psychotherapy, provided to persons without a drug/alcohol abuse or dependence diagnosis who are family members, other relatives, friends, acquaintances or live-in companions of the eligible recipient with a drug/alcohol abuse or dependence problem solely because of a relationship to the recipient. Payment will be made only for covered services directly provided to eligible MA recipients who have been diagnosed by a licensed physician as having a drug/alcohol abuse or dependence problem.

   (11)  Services delivered at locations other than approved drug/alcohol outpatient clinics with the exception of home visits under the conditions specified in §  1223.52(d) (relating to payment conditions for various services).

   (12)  Methadone maintenance clinic visits on days when the patient has take-home privileges, that is, self-administers methadone at home.

   (13)  Home visits not provided in accordance with the conditions specified in §  1223.52(d).

   (14)  Methadone maintenance clinic services provided before the date of the physician’s comprehensive medical examination, diagnosis and treatment plan.

   (15)  Services provided without a level of care assessment for each patient prior to admission to the clinic.

   (16)  Services provided within or beyond the 15th calendar day following intake, without the clinic’s supervisory physician’s review and approval of the patient’s level of care assessment, psychosocial evaluation, treatment plan and determination of the patient’s diagnosis as specified in §  1223.52(a)(6)(i).

Authority

   The provisions of this §  1223.14 amended under section 443.3(1) of the Public Welfare Code (62 P. S. §  443.3(1)).

Source

   The provisions of this §  1223.14 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 November 9, 2001, effective November 10, 2001, and apply retroactively to March 1, 1998, 31 Pa.B. 6153; amended November 8, 2002, effective November 9, 2002, 32 Pa.B. 5513. Immediately preceding text appears at serial pages (285058) to (285060).

Cross References

   This section cited in 55 Pa. Code §  1223.54 (relating to noncompensable services and items).



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