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PA Bulletin, Doc. No. 99-20



Medical Assistance Items and Services Requiring Prior Authorization

[29 Pa.B. 76]

   The purpose of this notice is to provide a listing of additional Medical Assistance items and services requiring prior authorization.

   Section 443.6(b)(7) of the Public Welfare Code (62 P. S. § 443.6(b)(7)) authorizes the Department of Public Welfare (Department) to add other items and services to its list of services requiring prior authorization by publication of notice in the Pennsylvania Bulletin.

   In addition to the items and services listed in section 443.6(b)(1)--(6) of the Public Welfare Code, the following items and services require prior authorization before payment will be made:

   1.  All home health services. The first visit will be approved following hospitalization, the onset of an illness which does not involve a hospitalization, the onset of a new primary diagnosis or the exacerbation of an existing diagnosis which causes a change in the recipient's condition and requires a change in the plan of treatment, even if the balance of services in the plan or treatment is disapproved.

   2.  Psychiatric partial hospitalization services that exceed the limit of 240 3-hour sessions (720 total hours) of psychiatric partial hospitalization in a 365 consecutive day period for recipients under 21 years of age.

   3.  Multisource legend brand name products, identified by the Department, having therapeutically equivalent ''A'' rated generic products available for substitution, when the licensed prescriber certifies that the particular brand name product is medically necessary for a specific recipient.

   4.  Multisource brand name products that are subject to a State Maximum Allowable Cost.

   5.  Anti-ulcer drugs as identified by the Department for one of the following situations:

   a.  When prescribed or dispensed for periods that exceed the initial 90 days of treatment. Prior authorization is not required if the product has an indication for the treatment of gastric or duodenal ulcers; the product's recommended dosage includes a short-term treatment for gastric or duodenal ulcers until a reduced maintenance therapy to prevent the recurrence of gastric or duodenal ulcers; and the daily dose is reduced to the recommended maintenance therapy.

   b.  When prescribed or dispensed concurrently with another anti-ulcer drug at any time.

   c.  When the prescription is changed from one anti-ulcer drug to another during the initial 90 days of treatment.

   6.  Behavioral health rehabilitative services not included on the Medical Assistance Fee Schedule provided to individuals under 21 years of age.

   7.  Medical Assistance case management services provided to individuals under 21 years of age.

Fiscal Impact

   The Department has required prior authorization of these services under Notices of Rule Change published at 24 Pa.B. 3761 (July 30, 1994); 25 Pa.B. 347 (January 28, 1995); 24 Pa.B. 4423 (August 27, 1994); 25 Pa.B. 3782 (September 9, 1995); and 24 Pa.B. 2654 (May 21, 1994), consequently, no future fiscal impact is anticipated as a result of these amendments.

Contact Person

   A copy of this notice is available for review at local County Assistance Offices. Interested persons are invited to submit written comments to this notice within 30 days of this publication. These comments should be sent to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515 Health and Welfare Building, Harrisburg, PA 17120.

   Persons with a disability may use the AT&T Relay services by calling (800) 654-5984 (TDD users) or (800) 654-5988 (Voice users). Persons who require another alternative should contact Thomas Vracarich in the Office of Legal Counsel at (717) 783-2209.


   Fiscal Note: 14-NOT-189. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 99-20. Filed for public inspection December 31, 1999, 9:00 a.m.]

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