55 Pa. Code § 1149.54 - Payment policies for orthodontic services

In addition to the payment policies established in this chapter, Chapters 1101 and 1150 (relating to the general provisions; and MA Program payment policies) and the MA Program fee schedule the following payment policies apply to orthodontic services:

(1) Payment for orthodontic services is made only if all of the conditions specified in § 1149.55 (relating to payment conditions for orthodontic services) are met.

(2) Payment for orthodontic services is subject to the limitations set forth in § 1149.56 (relating to payment limitations for orthodontic services).

(3) Payment is made only for those quarters during which the recipient is seen by the orthodontist and treatment is rendered.

(4) Payment for covered and approved orthodontic service is made on a quarterly basis as set forth in the MA Program fee schedule. The first quarter begins on the recipient's first appointment day after the Department has authorized payment for the orthodontic services.

(5) The fees listed in the MA Program fee schedule include all appliances furnished by the orthodontist during the course of the orthodontic treatment.

(6) The fees listed in the MA Program fee schedule for the first quarter of treatment includes the cost of diagnostic aids such as models, photographs, radiographs and the like except as noted in paragraph (7).

(7) Payment for diagnostic aids is made only if the Department requests the diagnostic aids for review before the decision is made to approve orthodontic treatment and the treatment is denied by the Department.

(8) Payment will be discontinued for persons who become ineligible for MA benefits during the course of the orthodontic treatment. The last payment will be for the quarter in which the recipient becomes ineligible.

(9) Payment is made for orthodontic services for persons receiving orthodontic treatment at the time their eligibility for MA benefits begins in accordance with the policies set forth in this chapter subject to the conditions set forth in §§ 1149.55 and 1149.56.

(10) Payment will not be made for recipients beginning orthodontic treatment through the Department of Health's Cleft Palate Program, Division of Rehabilitation.

Notes

55 Pa. Code § 1149.54

The provisions of this § 1149.54 adopted January 25, 1985, effective 1/15/1985, 15 Pa.B. 255; amended September 30, 1988, effective 10/1/1988, 18 Pa.B. 4418.

This section cited in 55 Pa. Code § 1149.56 (relating to payment limitations for orthodontic services).