Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES
PAYMENT FOR CLINIC AND EMERGENCY ROOM SERVICES
Section 1221.59 - Noncompensable services and items

(1) Services rendered in the hospital emergency room to a recipient who is admitted to the hospital the same day.

(2) Services and procedures that are available through other public agencies or private insurance plans.

(3) Physicians' services not listed in the MA Program Fee Schedule.

(4) Methadone maintenance.

(5) Prescribed medications and medical supplies. Payment for these services is made only to participating pharmacies and medical suppliers. Section 1221.51(1) (relating to general payment policy) describes an exception for specific vaccines provided in hospital outpatient clinics, if the hospital does not have a pharmacy enrolled in the MA Program, and independent medical/surgical clinics.

(6) Laboratory services. Payment for these services will be made only to participating laboratories.

(7) Surgical procedures and medical care provided in connection with sex reassignment. This includes, hormone therapy and release of vaginal adhesions.

(8) More than one flat visit fee or fee for a specific compensable service provided by an independent medical clinic, hospital outpatient department, medical school outpatient department or hospital emergency room on the same day, regardless of specialty, except as noted in § 1221.51(6) and (7).

(9) Nonemergency use of the emergency room. Services to patients who do not exhibit symptoms or have a diagnosis that is listed in Appendix A are not reimbursable unless the recipient declares that he does not have access to a primary care physician or an outpatient clinic to treat nonemergency situations. The hospital emergency room staff and the emergency room physician shall document in the patient's medical record the declaration of no access to primary care.