Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES
COVERED AND NONCOVERED SERVICES
Section 1153.14 - Noncovered services
Current through Register Vol. 54, No. 12, March 23, 2024
Payment will not be made for the following types of services regardless of where or to whom they are provided:
(Editor's Note: Under section 2(1) of the act of October 28, 2022 (P.L. 1632, No. 98), § 1153.14(1) is abrogated.)
(1) A covered psychiatric outpatient clinic, MMHT or partial hospitalization outpatient service conducted over the telephone.
(2) Cancelled appointments.
(3) Covered services that have not been rendered.
(4) An MA covered service, including psychiatric outpatient clinic, MMHT and partial hospitalization outpatient services, provided to inmates of State or county correctional institutions or committed residents of public institutions.
(5) Psychiatric outpatient clinic, MMHT or partial hospitalization outpatient services to residents of treatment institutions, such as individuals 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 licensed psychiatric outpatient clinics with the exception of MMHT under the conditions specified in § 1153.52(d) (relating to payment conditions for various services) or partial hospitalization outpatient facilities.
(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, MMHT services and psychiatric partial hospitalization outpatient services provided on the same day to the same individual, with the exception of clinical services not offered by the facility providing services to the individual.
(10) Covered psychiatric outpatient clinic services, MMHT services and psychiatric partial hospitalization outpatient services, with the exception of family psychotherapy, provided to persons without a mental diagnosis rendered by a psychiatrist in accordance with the current version of the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases-Chapter V, "Mental, Behavioral, and Neurodevelopmental Disorders."
(11) Psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization outpatient services provided to individuals with substance-related and addictive disorders, unless the individual has a primary diagnosis of a mental illness or emotional disturbance.
(12) Drugs, biologicals and supplies furnished to an individual receiving services at a psychiatric outpatient clinic or a partial hospitalization outpatient facility during a visit to the psychiatric outpatient clinic or partial hospitalization outpatient facility. These are included in the psychiatric outpatient clinic medication visit fee or partial hospitalization session payment. Separate billings from any source for items and services provided by the psychiatric outpatient clinic are noncompensable.
(13) Services not specifically included in the MA Program Fee Schedule are noncompensable.
(14) MMHT services not provided in accordance with the conditions specified in § 1153.52(d).
(15) Services provided beyond the 30th calendar day following intake, without review and approval of the initial assessment and treatment plan in accordance with § 1153.52(a)(7) and (8).
(16) The hours that the individual participates in an education program delivered in the same setting as a children and youth partial hospitalization outpatient 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 individual is in direct contact with a clinical staff person.
(17) Group psychotherapy provided in the individual's home.
(18) Psychiatric outpatient clinic and partial hospitalization outpatient services provided to nursing home residents on the grounds of the nursing home or under the corporate umbrella of the nursing home.
(19) Electroconvulsive therapy and electroencephalogram provided through MMHT.
(20) MMHT services provided on the same day as other home and community-based behavioral health services to the same individual with the exception of clinical services not offered by the psychiatric outpatient clinic.
The provisions of this § 1153.14 amended under section 201(2) of the Human Services Code (62 P.S. § 201(2)).
