Section 1141.2. Definitions

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

Abortion—The deliberate termination of a pregnancy before the fetus is viable.

Chronic condition—An illness which frequently recurs or persists for a period in excess of 3 months.

Consultation—A medical evaluation conducted by a specialist at the request of the attending practitioner. For the purposes of the Medical Assistance Program a consultation shall include taking a medical history, examining the patient and preparing a written report that is incorporated into the record of the patient.

Cosmetic surgery—A surgical procedure the primary purpose of which is to improve the appearance of the patient. The procedures include, but are not limited to, otoplasty for protruding ears or lop ears, rhinoplasty, except to correct internal nasal deformity, nasal reconstruction, excision of keloids, fascioplasty, osteoplasty for prognathism or micrognathism or both, dermabrasion, skin grafts and lipectomy.

Covered services—A benefit to which a Medical Assistance recipient is entitled under the Medical Assistance program.

Emergency situation—A condition in which immediate medical care is necessary to prevent the death or serious impairment of health of the individual.

Experimental procedure—A procedure that deviates from customary standards of medical practice, is not routinely used in the medical or surgical treatment of a specific illness or condition, or is not of proven medical value.

Family planning services—Those diagnostic services, treatments, drugs, supplies, devices and counseling services furnished to individuals to enable them to control the number and spacing of their children.

General medical examination—A medical evaluation conducted by the attending physician of the patient, whether a general practitioner or specialist, at the request of the patient. The evaluation shall consist of a physical examination, the evaluation of diagnostic studies, if warranted, and the recording of the findings in the medical file of the patient.

Institutionalized individual—A person who is one of the following:

(i) Involuntarily detained under a civil or criminal statute in a correctional, rehabilitative or mental retardation facility including a psychiatric hospital or other facility for the care and treatment of mental illness or mental retardation.

(ii) Confined under voluntary commitment in a psychiatric hospital, mental retardation facility or other facility for the care and treatment of mental illness or mental retardation.

Medical emergency care—Care rendered in response to the sudden and unexpected onset of a medical, not surgical condition, requiring medical, not surgical, intervention which the recipient secures immediately after the onset or as soon thereafter as the care can be made available, but in no case later than 72 hours after the onset. In order to determine whether a medical emergency existed the following criteria shall be applied:

(i) Severe symptoms have to occur. The symptoms must be sufficiently severe to cause a person to seek immediate medical aid. Some symptoms or conditions indicating medical emergency care are listed in Appendix C.

(ii) Severe symptoms must occur suddenly and unexpectedly. Subacute symptoms of a chronic condition would not qualify as a medical emergency. However, chronic symptoms that suddenly become severe enough to require immediate medical attention would qualify.

(iii) Immediate care was secured. A medical emergency would not be considered to exist if medical care were not rendered immediately after the patient reported his symptoms to the physician. A telephone call to a doctor would not fulfill this requirement if examination and treatment by the physician were deferred until the next day.

Medical examination requested by the Department—A medical evaluation conducted by the attending physician of the patient whether a general practitioner or specialist at the request of the Department. The evaluation shall consist of a physical examination, the evaluation of diagnostic studies, the recording of findings in the file of the patient and the completion of medical evaluation forms supplied by the Department.

Medical justification—Written documentation in the medical record of the patient indicating the specific health condition or risk that made the particular service the physician rendered, ordered or prescribed necessary.

Medically necessary—A service, item, procedure or level of care that is:

(i) Compensable under the Medical Assistance program.

(ii) Necessary to the proper treatment or management of an illness, injury or disability.

(iii) Prescribed, provided or ordered by an appropriate licensed practitioner in accordance with accepted standards of practice.

Mentally incompetent individual—A person who has been declared mentally incompetent by a Federal, State or local court of competent jurisdiction for any purpose unless he has been declared competent for the purposes which include the ability to consent to sterilization.

Noncompensable—A service a provider furnishes for which there is no provision for payment under Medical Assistance regulations.

Nonemergency medical services—A compensable physicians’ services other than those provided for condition urgently requiring medical intervention in order to sustain the life of the person to prevent damage to his health.

Physician—An individual licensed under the laws of this Commonwealth to practice medicine and surgery within the scope of the Medical Practice Act of July 20, 1974 (P. L. 551, No. 190) (63 P. S. § 421.10) or the Osteopathic Medical Practice Act (63 P. S. § § 271.1—271.18).

Short procedure unit—A unit of a hospital organized for the delivery of nonemergency surgical services to patients who do not remain in the hospital overnight.

Specialist—A physician who limits his practice to the study and treatment of one class of diseases or to treatment of specific organs or systems within the body, recognized by the American Medical Association or the American Osteopathic Association for his particular specialty.

Sterilization—A recognized medical procedure the primary purpose of which is to render the patient incapable of reproduction.

The provisions of this § 1141.2 adopted August 15, 1980, effective September 1, 1980, 10 Pa.B. 3386; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended April 27, 1984, effective April 28, 1984, 14 Pa.B. 1454; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (117364), (93481) to (93482) and (96099).

Notation

Cross References

This section cited in 55 Pa. Code § 1141.55 (relating to payment conditions for sterilizations); and 55 Pa. Code § 1141.59 (relating to noncompensable services).