Section 1150.63. Waivers

(a) The Department may waive the requirements of § 1150.51(6) (relating to general payment policies) upon written request by a provider.

(b) The Department, under extraordinary circumstances, will pay for a medical service or item that is not one for which the MA Program has an established fee. If a practitioner concludes that lack of the service or item would impair the recipient’s health, the practitioner may either give the recipient the prescription or order to take to the CAO, or send the prescription or order to the CAO by mail.

(c) The CAO shall forward the prescription and a completed Form MA 325 (Request for Waiver) to the Office of MA Programs where it will be reviewed by the Department’s medical consultants. The Office of MA Programs will notify the requestor of its decision. Section 1101.67 (relating to prior authorization) which requires a decision on requests for prior authorization within 21 days does not apply to requests for waivers.

(d) The Department will review each request using the following guidelines:

(1) Payment for the procedure is not allowable according to the fee schedule, is a type of service covered by the program and is generally accepted by the medical community.

(2) The procedure is not experimental.

(3) The therapeutic effectiveness of the procedure has been scientifically documented.

The provisions of this § 1150.63 adopted September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418.

Notation

Notes of Decisions

Waiver provision applies even if the provider is not involved in the MA Program. Walizer v. Department of Public Welfare, 611 A.2d 1359 (Pa. Cmwlth. 1992); appeal denied 619 A.2d 701 (Pa. Cmwlth. 1993).

Cross References

This section cited in 55 Pa. Code § 41.92 (relating to expedited disposition procedure for certain appeals); and 55 Pa. Code § 1150.51 (relating to general payment policies).