ADMINISTRATIVE SANCTIONS
§ 1241.81. Provider misutilization.
Providers determined to have billed for services inconsistent with MA Program regulations, to have provided services outside the scope of customary standards of practice, or to have otherwise violated the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).
Source The provisions of this § 1241.81 adopted December 6, 1980, effective December 1, 1980, 10 Pa.B. 4611.
APPENDIX A
SCREENING SERVICES REQUIRED EXAMINATIONS AND DIAGNOSTIC TESTS
The screening of an eligible MA recipient shall include the following examinations, evaluations and appropriate diagnostic tests as specified per age group.
(1) Individuals—Birth Through 18 Months
(i) Taking a health history from the parent or guardian.
(ii) Unclothed physical examination.
(iii) Developmental Appraisal—Denver or equivalent.
(iv) Growth Measurements.
(v) Metabolic Screening—PKU when appropriate.
(vi) Anemia Screening—Hemoglobin and/or Hematocrit when appropriate.
(vii) Lead Poisoning Evaluation when appropriate.
(viii) Sickle Cell Anemia Evaluation when appropriate.
(ix) Tuberculosis Testing when appropriate.
(x) Assessing and updating appropriate immunizations.
(2) Individuals—19 Months Through Age 20
(i) Taking of a health history from the parent.
(ii) Unclothed physical examination, including Tanner Score and blood pressure.
(iii) Developmental Appraisal.
(iv) Vision Test.
(v) Hearing Test.
(vi) Dental Examination.
(vii) Urine Screen for bacteria, sugar, albumin.
(viii) Malnutrition Evaluation.
(ix) Tuberculosis Testing when appropriate.
(x) Iron Anemia—Hemoglobin and Hematocrit when appropriate.
(xi) Lead Poisoning Evaluation when appropriate.
(xii) Sickle Cell Anemia Evaluation when appropriate.
(xiii) Assessing and updating appropriate immunizations when required.
APPENDIX B. [Reserved]
Source The provisions of this Appendix B reserved May 25, 1990, effective May 26, 1990, 20 Pa.B. 2751. Immediately preceding text appears at serial pages (124152) and (117509).
APPENDIX C. [Reserved]
Source The provisions of this Appendix C reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (58168).
APPENDIX D. EPSDT IMMUNIZATION GUIDELINES—
STATEMENT OF POLICY
Recommended Childhood Immunization Schedule
United States, January—December 1997
Vaccines11 are listed under the routinely recommended ages.
Bars
indicate range of acceptable ages for vaccination.
Shaded bars
indicate catch-up vaccination: at 11-12 years of age, Hepatitis B vaccine should be administered to children not previously vaccinated, and Varicella Virus vaccine should be administered to unvaccinated children who lack a reliable history of chickenpox.
Age [rArr ] 1 2 4 6 12 15 18 4-6 11-12 14-16 Vaccine[dtrif ] Birth mo mos mos mos mos mos mos yrs yrs yrs Hepatitis B2,3 Hep B-1 Hep B-2 Hep B-3 Hep B3 Diphtheria, Tetanus,
Pertussis4DTaP
or DTPDTaP
or DTPDTaP
or DTPDTaP or DPT 4 DTaP
or DTPTd H. influenzae type b5 Hib Hib Hib5 Hib 5 Polio6 Polio6 Polio Polio 5 Polio Measles, Mumps, Rubella7 MMR MMR 7 or MMR7
Varicella8 Var Var8
Approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).
1 This schedule indicates the recommended age for routine administration of currently licensed childhood vaccines. Some combination vaccines are available and may be used whenever administration of all components of the vaccine is indicated. Providers should consult the manufacturers’ package inserts for detailed recommendations.
2 Infants born to HBsAg-negative mothers should receive 2.5 µg of Merck vaccine (Recombivax HB®) or 10 µg of SmithKline Beecham (SB) vaccine (Engerix-B®). The 2nd dose should be administered ›= 1 mo after 1st dose.
Infants born to HBsAg-positive mothers should receive 0.5 mL hepatitis B immune globulin (HBIG) within 12 hrs of birth, and either 5 µg of Merck vaccine (Recombivax HB®) or 10 µg of SB vaccine (Engerix-B®) at a separate site. The 2nd dose is recommended at 1-2 mos of age and the 3rd dose at 6 mos of age.
Infants born to mothers whose HbsAg status is unknown should receive either 5 µg of Merck vaccine (Recombivax HB®) or 10 µg of SB vaccine (Engerix-B®) within 12 hrs of birth. The 2nd dose of vaccine is recommended at 1 mo of age and the 3rd dose at 6 mos of age. Blood should be drawn at the time of delivery to determine the mother’s HBsAG status; if it is positive, the infant should receive HBIG as soon as possible (no later than 1 wk of age). The dosage and timing of subsequent vaccine doses should be based upon the mother’s HBsAg status.3 Children and adolescents who have not been vaccinated against hepatitis B in infancy may begin the series during any childhood visit. Those who have not previously received 3 doses of hepatitis B vaccine should initiate or complete the series during the 11-12 year-old visit. The 2nd dose should be administered at least 1 mo after the 1st dose, and the 3rd dose should be administered at least 4 mos after the 1st dose, and at least 2 mos after the 2nd dose.
4 DTaP (diphtheria and tetanus toxoids and acellular pertussis vaccine) is the preferred vaccine for all doses in the vaccination series, including completion of the series in children who have received ›=1 dose of whole-cell DTP vaccine. Whole-cell DTP is an acceptable alternative to DTaP. The 4th dose of DTaP may be administered as early as 12 mos of age, provided 6 mos have elapsed since the 3rd dose, and if the child is considered unlikely to return at 15-18 mos of age. Td (tetanus and diphtheria toxoids, adsorbed, for adult use) is recommended at 11-12 yrs of age if at least 5 yrs have elapsed since the last dose of DTP, DTaP or DT. Subsequent routine Td boosters are recommended every 10 yrs.
5 Three H. influenzae type b (Hib) conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB® [Merck]) is administered at 2 and 4 mos of age, a dose at 6 mos is not required. After completing the primary series, any Hib conjugate vaccine may be used as a booster.
6 Two poliovirus vaccines are currently licensed in the US: inactivated poliovirus vaccine (IPV) and oral poliovirus vaccine (OPV). The following schedules are all acceptable by the ACIP, the AAP and the AAFP, and parents and providers may choose among them:
1. IPV at 2 and 4 mos; OPV at 12-18 mos and 4-6 yrs
2. IPV at 2, 4, 12-18 mos, and 4-6 yrs
3. OPV at 2, 4, 6-18 mos, and 4-6 yrs
The ACIP routinely recommends schedule 1. IPV is the only poliovirus vaccine recommended for immunocompromised persons and their household contacts.7 The 2nd dose of MMR is routinely recommended at 4-6 yrs of age or at 11-12 yrs of age, but may be administered during any visit, provided at least 1 mo has elapsed since receipt of the 1st dose, and that both doses are administered at or after 12 mos of age.
8 Susceptible children may receive Varicella vaccine (Var) during any visit after the 1st birthday, and unvaccinated persons who lack a reliable history of chickenpox should be vaccinated during the 11-12 year-old visit. Susceptible persons ›=13 yrs of age should receive 2 doses, at least 1 mo apart.
Source The provisions of this Appendix D adopted May 25, 1990, effective May 26, 1990, 20 Pa.B. 2791; amended January 11, 1991, effective January 18, 1991, 21 Pa.B. 165; amended September 27, 1991, effective September 28, 1991, 21 Pa.B. 4429; amended December 4, 1992, effective December 11, 1992, 22 Pa.B. 5785; amended August 1, 1997, effective August 2, 1997, 27 Pa.B. 3818. Immediately preceding text appears at serial pages (177234) to (177236) and (188507).
Cross References This appendix cited in 55 Pa. Code § 1221.51 (relating to general payment policy).
APPENDIX E. GUIDELINES ON CHILDHOOD LEAD
POISONING PREVENTION
Childhood Lead Poisoning Prevention Questionnaire
Does your child live in or regularly visit a house, a day-care center or a nursery school that was built before 1960 and has peeling or chipping paint?
Does your child live in a home built before 1960 that is being remodeled or renovated?
Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?
Have any of your children or their playmates had lead poisoning?
Do you give your child any home or folk remedies which may contain lead?
Does your child often come in contact with an adult who works with lead—in construction, welding, plumbing, pottery or other trades?
Does your child live near a lead smelter, a battery-recycling plant or other industrial sites likely to release lead?
Does your home plumbing have lead pipes or copper with lead solder joints?
Under recent Federal clarification, a child, whose parent has answered ‘‘yes’’ to one or more of the risk assessment questions, is determined to be at high risk. A child, whose parent has answered ‘‘no’’ to all questions, is determined to be at low risk. We believe that most MA eligible children will be at high risk for lead poisoning. The EP test is not effective and is no longer acceptable as a screening test for lead poisoning. The use of the blood lead test is now required when screening Medicaid-eligible children for lead toxicity, whether they are determined high risk or low risk.
Screening Schedule
I. For children 6 to 36 months of age who are at LOW risk for HIGH dose lead exposure by questionnaire: an initial blood lead (PbB) test at 12 months of age and as follows:
A. If PbB test result: ‹10 ug/dL, retest at 24 months.
B. If PbB test result: 10-14 ug/dL, retest every 3 to 4 months. After 2 consecutive measurements are ‹10 ug/dL or three are ‹=15 ug/dL, retest child in 1 year.
C. If PbB test result ›=15 ug/dL, case manage and retest every 3 to 4 months.
II. For children 6 to 36 months of age who are at HIGH risk for HIGH dose exposure by questionnaire an initial PbB test at 6 months of age and as follows:
A. If PbB test result is ‹10 ug/dL, rescreen every 6 months. After 2 subsequent consecutive measurements are ‹10 ug/dL or three are ‹=15 ug/dL, testing frequency can be decreased to once a year.
B. If PbB test result 10-14 ug/dL, rescreen child every 3 to 4 months. After 2 subsequent consecutive measurements ‹10 ug/dL or three are ‹=15 ug/dL, testing frequency can be decreased to once a year.
III. For children 36 to 72 months of age:
As for younger children, a questionnaire should be used at each routine office visit of children from 36 to 72 months of age. Any child at HIGH risk by questionnaire who has not been previously tested should be tested. All children who have had venous blood lead tests ›=15 ug/dL or who are at risk by questionnaire should be screened at least once a year until their sixth birthday (age 72 months) or later, if indicated (e.g. developmentally delayed with pica). Children should also be screened any time history suggests exposure has increased.
Follow up for all Children 6 to 72 months
at PbB Levels ›15 ug/dL
A. If PbB 10-14 rescreen in 3-4 months or more often is indicated, provide family with education and nutritional counseling, and take a detailed environmental history to identify any obvious sources or pathways of lead exposure. It is unlikely that there is a single predominant source of lead exposure for most of these children, thus, a full home inspection is not recommended. It is prudent, however, to try to decrease exposure to lead with some simple interventions.
B. If PbB 15-19 ug/dL: same as preceding, plus discuss interventions to reduce PbB levels. If the PbB persists at this level, environmental investigation and abatement.
C. If PbB 20-44 ug/dL: same as for all of the preceding, plus venous confirmation, medical evaluation and follow-up.
D. If 45-69 ug/dL: same as for all of the preceding, plus URGENT medical and environmental follow-up.
E. If ›=70 ug/dL (VENOUS) or symptomatic lead poisoning a MEDICAL EMERGENCY, requiring immediate inpatient chelation therapy plus the same as for all preceding.
Elevated PbB results obtained on capillary screening specimens are presumptive and must be confirmed using venous PbB as follows: less than 10 ug/dL not applicable; 10-14 ug/dL not applicable; 15-19 ug/dL within 1 month; 20-44 ug/dL within 1 week; 45-69 ug/dL within 48 hours; greater than or equal to 70 ug/dL immediately.
The Department currently reimburses for blood lead testing through distinct procedure codes listed on the MA Fee Schedule and as a component of the Early and Periodic Screening, Diagnosis and Treatment Program.
NOTE: For a free copy of the October 1991 CDC Statement contact the Pennsylvania Department of Health, Childhood Lead Poisoning Prevention Program at (717) 783-8451.
Source The provisions of this Appendix E adopted August 27, 1993, effective August 28, 1993, 23 Pa.B. 4119; amended April 15, 1994, effective upon publication and apply retroactively to December 23, 1993, 24 Pa.B. 1973. Immediately preceding text appears at serial pages (184971) to (184972) and (181903).
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