§ 1230.1. Policy.

 The MA Program covers the technical components for specific radiological and cardiovascular services rendered to eligible recipients by approved organizations enrolled as providers under the program. The service shall be ordered by a licensed practitioner and the medical necessity for the service shall be established. Payment for portable X-ray services is subject to this chapter, Chapter 1101 (relating to general provisions) and the limitations established in Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule.

   The provisions of this §  1230.1 adopted August 13, 1982, effective August 14, 1982, 12 Pa.B. 2688; 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 (117495) to (117496).

SCOPE OF BENEFITS

§ 1230.21. Scope of benefits for the categorically needy.

 Categorically needy recipients are eligible for the full range of portable X-ray services compensable under the MA Program.

 Medically needy recipients are eligible for the full range of portable X-ray services compensable under the MA Program.

 State Blind Pension recipients are not eligible for portable X-ray services unless they are also either categorically or medically needy.

 General Assistance recipients, age 21 to 65, whose MA benefits are funded solely by State funds, are eligible for medically necessary basic health care benefits as defined in Chapter 1101 (relating to general provisions). See §  1101.3(e) (relating to scope).

   The provisions of this §  1230.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995.

PROVIDER PARTICIPATION

§ 1230.41. Participation requirements.

 In addition to the participation requirements established in Chapter 1101 (relating to general provisions), portable X-ray providers shall meet the participation requirements of this section:

   (1)  Portable X-ray providers shall be currently Medicare certified or currently certified by the Department of Health as meeting standards comparable to those of Medicare.

   (2)  Portable X-ray equipment shall be inspected and registered in accordance with the provisions of 25 Pa. Code Part I, Subpart D, Article V (relating to radiological health).

 (a)  Providers shall meet the ongoing responsibilities of this section in addition to the ongoing responsibilities established in §  1101.51 (relating to ongoing responsibilities of providers).

 (b)  State and Federal officials or their authorized agents may conduct onsite reviews in order to verify information furnished as a basis for payment under the MA Program and to establish the provider’s usual and customary charge to the general public, as defined in Chapter 1101 (relating to general provisions). Reviews shall be conducted during normal hours of operation or at a time mutually agreeable to the officials and the providers. During the course of the review, the provider shall ensure that the reviewers have access to, and are permitted to photograph, photocopy or duplicate:

   (1)  X-ray films and reports of studies performed and billed to the Department.

   (2)  Procedure manuals, records and documents necessary to determine whether payment for services is or was due under the program and whether services are or were provided in compliance with State and Federal law.

 (c)  X-rays performed and billed to the Department shall be of good technical and diagnostic quality. The provider shall properly label each X-ray film to indicate:

   (1)  The patient’s name.

   (2)  The date of service.

   (3)  The type of view.

   (4)  Right or left side.

   The provisions of this §  1230.42 adopted August 13, 1982, effective August 14, 1982, 12 Pa.B. 2688.

PAYMENT FOR PORTABLE X-RAY SERVICES

§ 1230.51. General payment policy.

 Payment is made for covered services provided by participating providers to eligible recipients in the patients’ home and in skilled nursing and intermediate care facilities, subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA fee schedule.

 (a)  Portable X-ray procedures billed to the Department shall be based on a practitioner’s written request. The written request must include:

   (1)  The practitioner’s name and medical license number.

   (2)  The recipient’s name and address.

   (3)  The recipient’s case number.

   (4)  The date of the request.

   (5)  The handwritten signature of the practitioner or the practitioner’s designated employe.

   (6)  The number and type of X-ray studies requested.

   (7)  The diagnosis or reason the X-rays were ordered.

   (8)  The reasons for the need for portable X-ray study rather than office X-ray.

 (b)  Payment for transporting portable X-ray equipment from the provider’s office to the place of service will be made in accordance with Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule and the limitation in §  1230.53 (relating to limitation on payment).

 (a)  For all portable X-ray services, the provider’s maximum payment is the lowest of:

   (1)  The provider’s usual and customary charge to the general public.

   (2)  The upper limits set by Medicare or Medicaid.

   (3)  The maximum fees or rates established in the MA Program fee schedule.

 (b)  Payment for transportation of portable X-ray or electrocardiogram equipment or both and personnel is limited to one payment per trip to each place of service, regardless of the number of services performed for different recipients at that place of service. If an X-ray and electrocardiogram are performed at one place of service, payment will only be made for transporting the X-ray equipment.

 (c)  Payment for portable X-ray services limited to those services listed in the MA Program fee schedule.

   The provisions of this §  1230.53 adopted August 13, 1982, effective August 14, 1982, 12 Pa.B. 2688; 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 (117498) to (117499).

 Payment will not be made to any portable X-ray provider for:

   (1)  Procedures not listed in the MA Program fee schedule.

   (2)  Services provided to a hospitalized recipient, including a recipient in a psychiatric hospital.

   (3)  Services provided to a recipient in a licensed practitioner’s office.

   (4)  Routine screening such as an examination without a diagnosis or suspected medical condition.

   The provisions of this §  1230.54 adopted August 13, 1982, effective August 14, 1982, 12 Pa.B. 2688; 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 page (117499).

UTILIZATION REVIEW

§ 1230.71. Scope of claim review procedures.

 Claims submitted for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101 (relating to general provisions).

   The provisions of this §  1230.71 adopted August 13, 1982, effective August 14, 1982, 12 Pa.B. 2688.

ADMINISTRATIVE SANCTIONS

§ 1230.81. Provider misutilization.

 Providers who bill for service inconsistent with MA Program regulations, provide service outside the scope of customary standards of practice, or otherwise violate the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).

   The provisions of this §  1230.81 adopted August 13, 1982, effective August 14, 1982, 12 Pa.B. 2688.

APPENDIX A. [Reserved]

   The provisions of this Appendix A reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial pages (75121) to (75122).