PAYMENT FOR SERVICES
§ 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).
Authority 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).
Source The provisions of this § 1150.51 adopted January 7, 1983, effective January 1, 1983, 13 Pa.B. 305; amended September 30, 1983, effective May 14, 1983, 13 Pa.B. 2975; amended October 28, 1983, effective January 1, 1984, 13 Pa.B. 3303; amended September 7, 1984, effective July 1, 1984, 14 Pa.B. 3252; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended August 11, 1989, effective immediately and apply retroactively to March 1, 1988, 19 Pa.B. 3391; amended July 9, 2004, effective January 1, 2004, 34 Pa.B. 3596. Immediately preceding text appears at serial pages (251207) to (251209).
Cross References This section cited in 55 Pa. Code § 1150.63 (relating to waivers).
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