Section 1141.53. Payment conditions for outpatient services

(a) Payment is made for services performed in an approved Short Procedure Unit (SPU) only if the service could not be appropriately and safely performed in the physician’s office, the clinic, or the emergency room of a hospital because of the medical need for inpatient hospital resources such as an operating room and the administration of general anesthesia.

(b) Specialists’ examinations and consultations require prior authorization from the Department as described in § 1101.67 (relating to prior authorization).

(c) Physicians’ services provided to recipients in skilled and intermediate care facilities by the physician administrator or medical director of the facility are compensable only if the administrator’s or medical director’s salary does not include payment for patient care.

(d) Payment for sterilizations is subject to the conditions set forth in § 1141.55 (relating to payment conditions for sterilizations).

(e) Payment for abortions is subject to the conditions set forth in § 1141.57 (relating to payment conditions for necessary abortions).

(f) All covered outpatient physicians’ services billed to the Department shall be performed by such physician either personally or by a registered nurse, physician’s assistant, or a midwife under the physician’s direct supervision.

(g) The Department pays a $10 per month fee only to physicians who are approved by the Department to participate in the restricted recipient program as set forth in § 1101.91 (relating to recipient misutilization and abuse). The physician is paid the $10 monthly fee for the restricted recipient under the physician’s medical supervision. This fee is in addition to fees paid to the physician during the month for necessary and covered medical services furnished to restricted recipient.

The provisions of this § 1141.53 adopted August 15, 1980, effective September 1, 1980, 10 Pa.B. 3386; amended October 8, 1982, effective October 9, 1982, 12 Pa.B. 3647; amended April 27, 1984, effective April 28, 1984, 14 Pa.B. 1454; amended September 7, 1984, effective July 1, 1984, 14 Pa.B. 3252; amended November 30, 1984, effective December 1, 1984, 14 Pa.B. 4370, and by approval of the court of a joint motion for modification of a consent agreement dated February 11, 1985 in Turner v. Beal, et al., C.A. No. 74-1680 (E.D. Pa. 1975). Immediately preceding text appears at serial pages (96100) to (96101).

Notation

Authority

The provisions of this § 1141.53 amended under sections 403(a) and (b), 443.2(1) and (2), 443.3(1) and (2)(i)—(v), 443.4, 443.6 and 509 of the Public Welfare Code, § § 403(a) and (b), 443.2(1) and (2), 443.3(1), 443.3(2)(i)—(v), 443.4, 443.6 and 509 (62 P. S. § § 403(a) and (b), 443.2(1) and (2), 443.3(1), 443.3(2)(i)—(v), 443.4, 443.6 and 509).

Cross References

This section cited in 55 Pa. Code § 1141.51 (relating to general payment policy); and 55 Pa. Code § 1141.52 (relating to payment conditions for various services).