55 Pa. Code § 1150.51 - General payment policies
(a)
Payment will be made to providers. Payment may be made to practitioners'
professional corporations or partnerships if the professional corporation or
partnership is composed of like practitioners. Payment will be made directly to
practitioners if they are members of professional corporations or partnerships
composed of unlike practitioners. Practitioners who render services at eligible
provider hospitals, either through direct employment or through contract, may
direct that payment be made to the eligible provider hospital. Payment will be
made for medical services or items covered by the program, furnished by
enrolled providers subject to the conditions and limitations established in
this chapter, Chapter 1101 (relating to general provisions) and the specific
chapters for each provider type. Payment will not be made for a covered medical
service or item if payment is available from another agency or another
insurance or health program. Payment will not be made for services that are not
medically necessary.
(b) To the
extent that this chapter conflicts with the regulations that relate to
reimbursement for various services or items contained in the specific MA
provider chapters which were in effect on January 1, 1983, this chapter
controls. To the extent that this chapter does not address a reimbursement
question answered by a regulation contained in a specific provider chapter, the
regulation in the specific provider chapter controls.
(c) This chapter shall be used by
practitioners, hospitals providing outpatient and emergency room services,
facilities and practitioners rendering services which require a PSR or second
opinion, or both; independent clinics; and other noninstitutional providers
including medical supplies, independent laboratories, ambulance companies,
pharmacies, portable X-ray providers, funeral directors and home health
agencies.
(d) Each section of the MA
Program Fee Schedule which is contained in the Provider's Handbook includes the
following:
(1) An all-inclusive listing of
covered services and items.
(2) The
provider type eligible under MA to bill for each service and item.
(3) The appropriate procedure code for each
service or item.
(4) The
appropriate type of service for each procedure code.
(5) The applicable limitations for each
service or item.
(6) The maximum
allowable fee for each service or item.
(7) For surgical and obstetrical procedures,
the allowable number of postoperative or postpartum days during which no
additional payment will be made for office or home visits for a purpose other
than early and periodic screening, diagnosis and treatment visits to the
practitioner who performed the procedure. This policy does not apply to other
members of a group practice of a different specialty.
(8) The maximum allowable fee for anesthesia
for each procedure.
(e)
The maximum payment made to a practitioner for all services provided to a
patient during any one period of hospitalization will be the lowest of:
(1) The practitioner's usual charge to the
general public for the same service.
(2) The MA maximum allowable fee.
(3) A maximum reimbursement limit of $1,000
unless a procedure provided during the hospitalization has a fee which exceeds
$1,000, in which case that fee is the maximum reimbursement for the period of
hospitalization.
(f)
Maximum payments to various categories shall be as follows:
(1) The maximum payment made to a provider or
practitioner, or their professional corporation or partnership, or a clinic for
outpatient procedures provided to a nonhospitalized patient for treatment
during 1 day will be the lowest of:
(i) The
usual charge to the general public for the same service.
(ii) The MA maximum allowable fee.
(iii) A maximum reimbursement limit of $500
per day unless the outpatient procedure has a fee which exceeds $500, in which
case the fee is the maximum reimbursement on a daily basis, for that day
only.
(2) The maximum
payment made to a dentist, medical supplier or pharmacy, or their professional
corporation or partnership, or a clinic for outpatient procedures provided to a
nonhospitalized patient for treatment during 1 day will be the lower of:
(i) The usual charge to the general public
for the same service.
(ii) The MA
maximum allowable fee.
(g) Services shall be performed in an
efficient and economical manner.
(h)
No payment will be made to a provider:
(1)
For physical therapy except when provided and billed as an integral part of
hospital inpatient, hospital outpatient, rural health clinic, home health
agency or nursing home services.
(2) For a surgical procedure and an office or
clinic visit for the same patient on the same day.
(3) For standby services except to
practitioners for Cesarean sections and high risk deliveries.
(4) For an emergency room visit and a
hospital clinic visit for the same patient on the same day for the same
condition.
(5) For the removal of
sutures and casts.
(6) For
procedures not listed in the MA Program Fee Schedule, except as specified in §
1150.63 (relating to
waivers).
Notes
The provisions of this § 1150.51 amended under sections 201(2), 443.1(1) and (4), 443.2(2)(ii) and 443.4 of the Public Welfare Code (62 P. S. §§ 201(2), 443.1(1) and (4), 443.2(2)(ii) and 443.4).
This section cited in 55 Pa. Code § 1150.63 (relating to waivers).
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