Section 127.103. Outpatient providers subject to the Medicare fee schedule—generally

(a) When services are rendered by outpatient providers who are reimbursed under the Medicare Part B Program pursuant to the Medicare fee schedule, the payment under the act shall be calculated using the Medicare fee schedule as a basis. The fee schedule for determining payments shall be the transition fee schedule as determined by the Medicare carrier.

(b) The insurer shall pay the provider for the applicable Medicare procedure code even if the service in question is not a compensated service under the Medicare Program.

(c) If a Medicare allowance does not exist for a reported HCPCS code, or successor codes, the provider shall be paid either 80% of the usual and customary charge or the actual charge, whichever is lower.

(d) When calculating payment for all services rendered on and before December 31, 1995, all rate increases, periodic adjustments and modifications incorporated into the Medicare Part B Fee Schedule shall be used. The effective date of these changes under Medicare shall also be the effective date of the fee changes under the act, as provided in § 127.151 (relating to medical fee updates prior to January 1, 1995—generally).

(e) Fee updates subsequent to December 31, 1994, shall be in accordance with § § 127.152 and 127.153 (relating to medical fee updates on and after January 1, 1995—generally; and medical fee updates on and after January 1, 1995—outpatient providers, services and supplies subject to the Medicare fee schedule).

Notation

Cross References

This section cited in 34 Pa. Code § 127.101 (relating to medical fee caps—Medicare); 34 Pa. Code § 127.119 (relating to payments for services using RCCs); 34 Pa. Code § 127.126 (relating to new providers); 34 Pa. Code § 127.153 (relating to medical fee updates on and after January 1, 1995—outpatient providers, services and supplies subject to the Medicare fee schedule).