Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1141 - PHYSICIANS' SERVICES
PAYMENT FOR PHYSICIANS' SERVICES
Section 1141.54 - Payment conditions for inpatient services

Universal Citation: 55 PA Code ยง 1141.54

Current through Register Vol. 54, No. 44, November 2, 2024

(a) A physician is eligible to bill the Department for services he provides to a hospitalized recipient:

(1) If inpatient hospital care is medically necessary as certified by the hospital's utilization review committee or the Department's Bureau of Utilization Review.

(2) For an outpatient (OP) designated procedure, only if the medical condition of the patient is such that to perform the procedure on an outpatient basis could result in undue risk to the life or health of the patient. Detailed documentation supporting the condition of risk to the life or health of the patient shall be included in the patient's medical record and on the claim submitted for payment.

(3) If the hospital has not been denied payment by the Department for the day the service was provided.

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

(c) Payment for hysterectomies is subject to the conditions set forth in § 1141.56 (relating to payment conditions for hysterectomies).

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

(e) [Reserved].

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

The provisions of this §1141.54 issued under sections 403(a) and (b), 443.2(1) and (2), 443.3(1) and (2)(i)-(v), 443.4 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 and 509 (62 P. S. §§ 403(a) and (b) 443.2(1) and (2), 443.3(1), 443.3(2)(i)-(v), 443.4 and 509).

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).

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