Section 1153.14. Noncovered services

Payment will not be made for the following types of services regardless of where or to whom they are provided:

(1) A covered clinic or partial hospitalization service conducted over the telephone.

(2) Cancelled appointments.

(3) Covered services that have not been rendered.

(4) A MA covered service, including psychiatric clinic and partial hospitalization services, provided to inmates of State or county correctional institutions or committed residents of public institutions.

(5) Psychiatric outpatient clinic or partial hospitalization services to residents of treatment institutions, such as, persons who are also being provided with room or board or both, and services, on a 24-hour-a-day basis by the same facility or distinct part of a facility or program.

(6) Services delivered at locations other than approved psychiatric outpatient clinics or partial hospitalization facilities with the exception of home visits under the conditions specified in § 1153.52(d) (relating to payment conditions for various services).

(7) Vocational rehabilitation, occupational or recreational therapy, referral, information or education services, case management, central intake or records, training, administration, program evaluation, research or social services provided in psychiatric outpatient clinics.

(8) Case management, central intake or records, training, administration, social rehabilitation, program evaluation or research provided in psychiatric outpatient partial hospitalization facilities.

(9) Psychiatric outpatient clinic services and psychiatric partial hospitalization provided on the same day to the same patient.

(10) Covered psychiatric outpatient clinic services and psychiatric partial hospitalization services, with the exception of family psychotherapy, provided to persons without a mental disorder or mental retardation diagnosis rendered by a psychiatrist in accordance with the International Classification of Diseases—ICD-9-CM, Chapter V, ‘‘Mental Disorders.’’

(11) Psychiatric outpatient clinic and psychiatric partial hospitalization services provided to patients with drug/alcohol abuse or dependence problems, such as alcohol dependence and nondependent abuse of drugs, alcohol psychoses, and drug psychoses, unless the patient has a primary diagnosis of a nondrug/alcohol abuse/dependence related mental disorder.

(12) Drugs and biologicals and supplies furnished to psychiatric clinic or psychiatric partial hospitalization patients during a visit to the clinic or facility. These are included in the clinic medication visit fee or partial hospitalization session payment. Separate billings from any source for items and services provided in the clinic are noncompensable.

(13) Services not specifically included in the MA Program Fee Schedule are noncompensable.

(14) Home visits not provided in accordance with the conditions specified in § 1153.52(d).

(15) Services provided beyond the 15th calendar day following intake, without the psychiatrist’s review and approval of the initial assessment and treatment plan.

(16) The hours that the client participates in an education program delivered in the same setting as a children and youth partial hospitalization program unless, in addition to the teacher, a clinical staff person works with the child in the classroom. The Department will reimburse for only that time during which the client is in direct contact with a clinical staff person.

(17) Group psychotherapy provided in the patient’s home.

(18) Psychiatric clinic and partial hospitalization services provided to nursing home residents on the grounds of the nursing home or under the corporate umbrella of the nursing home.

The provisions of this § 1153.14 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (86830) to (86832).