Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1221 - Clinic and Emergency Room Services
GENERAL PROVISIONS
Section 1221.2 - Definitions

Universal Citation: 55 PA Code § 1221.2

§ 1221.2. Definitions

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

Abortion-The deliberate termination of a pregnancy.

Acute illness-A brief illness marked by the sudden onset of severe symptoms.

Clinic-A hospital clinic, medical school clinic, or independent clinic that provides preventative, diagnostic, therapeutic, rehabilitative or palliative services on an outpatient basis. The clinic is distinct from a group practice in that it has a director, an organized structure, a written program designed to implement the objectives of the clinic, and a professional and administrative quality review program that evaluates the effectiveness of the outpatient service in relation to the stated objectives.

Contract physician-A physician who is paid for professional services by salary or other arrangement such as hourly wage or per diem, by an employer such as a hospital, clinic, or governmental agency. An individual physician may be both an independent and contract physician. The fact that a physician is under contract does not preclude the physician from providing services on a fee for service basis to the private patients of the physician.

Emergency accident care-The initial examination and treatment performed in connection with and within 72 hours following an injury. Examples of emergency accident care include but is not limited to the following: removal of foreign body in the eye, treatment of abrasions, contusions, acute sprains or strains, nose bleeds-caused by trauma, insect bites or stings, choking on food, drink, or foreign body, resuscitation of drowning or smoke inhalation victims, or treatment of concussion, or poisoning-chemical or drug.

Emergency medical care-edical care rendered in response to the sudden onset of a medical condition requiring medical, not surgical, intervention to sustain the life of the person or to prevent damage to the person's health and which the recipient secures immediately after the onset, or as soon thereafter as the care can be made available, but in no case later than 72 hours after the onset. In order to determine whether a medical emergency existed and, therefore, whether benefits for outpatient services in connection with the treatment of the condition are payable on an emergency basis, the following criteria shall be applied:

(i) Severe symptoms have to occur-The symptoms must be sufficiently severe to cause a person to seek immediate medical aid. Some symptoms or conditions indicating medical emergency care are listed in Appendix A.

(ii) Severe symptoms must occur suddenly and unexpectedly-Subacute symptoms of a chronic condition would not qualify as a medical emergency. However, chronic symptoms that suddenly become severe enough to require immediate intervention would qualify.

Hospital emergency room-An entity within a hospital, organizationally distinct from other outpatient facilities, the primary function of which is to provide emergency accident and emergency medical or surgical care.

Hospital outpatient clinic-A hospital operated facility that provides primary nonemergency health care on an outpatient basis. The hospital may contract out this function but the hospital shall be recognized as the provider.

Hospital outpatient department-An organizational division of a hospital composed of hospital outpatient clinics designed to provide comprehensive or specialized medical care on an outpatient basis. For the purpose of reimbursement under this chapter, a hospital outpatient department shall not include the hospital emergency room, outpatient psychiatric clinic, or outpatient drug and alcohol clinic when the hospital operates such facilities directly or through contract agreements. Reimbursement for outpatient psychiatric services are subject to Chapter 1153 (relating to outpatient psychiatric services). Reimbursement for outpatient drug and alcohol services are subject to Chapter 1223 (relating to outpatient drug and alcohol clinic services).

Independent medical clinic-A free-standing facility which provides comprehensive primary health care and which is neither located in a hospital owned nor under the management and control of the hospital. An independent medical clinic shall be operated by a public or private nonprofit corporation other than a hospital or corporation that owns or operates a hospital.

Independent physician-A physician who is paid for professional services on a fee-for-service basis. The physician may be in private practice alone or in a group with other physicians. An independent physician or group may be incorporated.

Institutionalized individual-A person who is one of the following:

(i) involuntarily detained under a civil or criminal statute in a correctional, rehabilitative or mental retardation facility including a psychiatric hospital or other facility for the care and treatment of mental illness or mental retardation.

(ii) confined under voluntary commitment in a psychiatric hospital, mental retardation facility or other facility for the care and treatment of mental illness or mental retardation.

Medical school clinic-A primary health care facility operated by a medical college located in the Commonwealth of Pennsylvania which has been fully accredited by the Association of American Medical Colleges or the American Medical Association and which has an agreement with a hospital to serve as its outpatient department.

Medical school outpatient department-A term used to describe collectively all medical school clinics operated by a medical college. For the purpose of reimbursement under this chapter, a medical school outpatient department shall not include the outpatient psychiatric clinic or outpatient drug and alcohol clinic regardless of whether the medical school operates such facilities directly or through contract agreements. Reimbursement for outpatient psychiatric services are subject to Chapter 1153. Reimbursement for outpatient drug and alcohol services are subject to Chapter 1223.

Mentally incompetent individual-A person who has been declared mentally incompetent by a Federal, State or local court of competent jurisdiction for any purpose unless he has been declared competent for the purposes which include the ability to consent to sterilization.

Noncompensable item-A service a provider furnishes for which there is no provision for payment under MA regulations.

Nonemergency medical services-A compensable physicians' services provided for conditions not requiring immediate medical intervention in order to sustain the life of the person or to prevent damage to his health.

Nonprofit-A term which describes a private agency, institution or organization which is a corporation or association, or is owned or operated by one or more corporations or associations, no part of the net earnings of which inures, or may lawfully inure to the benefit of a private shareholder or individual.

Physician-An individual licensed under the laws of the Commonwealth to practice medicine and surgery within the scope of the Medical Practice Act 1974 (63 P. S. § 421.11) or the Osteopathic Medical Practice Act (63 P. S. §§ 271.1-271.18).

Primary health care-Preventive, diagnostic, therapeutic, rehabilitative or palliative services provided by or under the supervision of a physician.

Rural health clinic-A clinic that is located in a rural area designated by the Department of Health and Human Services as a shortage area with respect to primary health care. Rural health clinics so designated participate in the Medical Assistance program subject to the regulations set forth in Chapter 1229 (relating to health maintenance organization services).

Support services-The basic facilities, supplies and ancillary services necessary to deliver health care on an outpatient basis.

Surgical services-Those procedures listed in the Medical Assistance program fee schedule.

Visit-A face-to-face encounter between a patient and a member of the independent clinic, hospital outpatient department or hospital emergency room staff for the purpose of receiving medical services provided by or under the direction of a physician. Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day constitute a single visit.

(The provisions of this § 1221.2 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418.)
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