CHAPTER 1129. RURAL HEALTH CLINIC SERVICES

GENERAL PROVISIONS

Sec.


1129.1.    Policy.
1129.2.    Definitions.

SCOPE OF BENEFITS


1129.21.    Scope of benefits for the categorically needy.
1129.22.    Scope of benefits for the medically needy.
1129.23.    Scope of benefits for State Blind Pension recipients.
1129.24.    Scope of benefits for General Assistance recipients.

PROVIDER PARTICIPATION


1129.41.    Participation requirements.
1129.42.    Ongoing responsibilities of providers.

PAYMENT FOR RURAL HEALTH CLINIC SERVICES


1129.51.    General payment policy.
1129.52.    Payment policy for provider rural health clinics.
1129.53.    Payment policy for independent rural health clinics.
1129.54.    Payment conditions for various services.
1129.55.    Limitations on payment.
1129.56.    Noncompensable services and items.

UTILIZATION CONTROL


1129.71.    Scope of claims review procedures.

ADMINISTRATIVE SANCTIONS


1129.81.    Provider misutilization.

Authority

   The provisions of this Chapter 1129 issued under sections 403 and 443.3(1) of the Public Welfare Code (62 P. S. § §  403 and 443.3(1)), unless otherwise noted.

Source

   The provisions of this Chapter 1129 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597, unless otherwise noted.

Cross References

   This chapter cited in 55 Pa. Code §  1101.31 (relating to scope); and 55 Pa. Code §  1101.95 (relating to conflicts between general and specific provisions).

GENERAL PROVISIONS


§ 1129.1. Policy.

 The MA Program provides payment for medical services provided under the auspices of a rural health clinic. Payment for rural health clinic services rendered to eligible recipients by rural health clinics enrolled as providers under the program is subject to this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule.

Source

   The provisions of this §  1129.1 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597; 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 (117356).

§ 1129.2. Definitions.

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

   Certified registered nurse practitioner—A registered nurse licensed in this Commonwealth who is currently certified by the State Board of Medicine and the State Board of Nursing as a certified registered nurse practitioner and who meets the qualifications for a nurse practitioner as set forth at 42 CFR 481.2(b).

   Covered service—A benefit to which a MA recipient is entitled under the Medical Assistance program.

   Independent rural health clinic—A clinic that:

     (i)   Meets the requirements for participation in the MA Program as set forth at 42 CFR 481.1.

     (ii)   Is not part of a hospital, skilled nursing facility or home health agency.

   Nurse midwife—A registered nurse licensed in this Commonwealth who is currently certified by the State Board of Medicine to practice midwifery.

   Physician—An individual licensed to practice medicine and surgery under section 10 of the Medical Practice Act of 1974 (63 P. S. §  421.10) (Repealed) or the Osteopathic Medical Practice Act (63 P. S. § §  271.1—271.18).

   Physician assistant—An individual currently certified as a physician assistant by the State Board of Medicine or by the State Board of Osteopathic Medicine and who meets the qualifications for a physician assistant as set forth at 42 CFR 481.2(d).

   Provider rural health clinic—A clinic that:

     (i)   Meets the requirements for participation in the MA Program as set forth at 42 CFR 481.1.

     (ii)   Is an integral part of a hospital, skilled nursing facility or home health agency.

   Registered nurse—An individual licensed in this Commonwealth by the State Board of Nursing to practice professional nursing.

   Rural health clinic personnel—A physician, certified registered nurse practitioner, registered nurse, nurse midwife or physician assistant who by contract or agreement with a rural health clinic provides medical services for the rural health clinic.

   Rural health clinic service—A service provided by rural health clinic personnel or an item furnished incident to services provided by rural health clinic personnel the cost of which is included in allowable costs for Medicare purposes under the Medicare program as set forth at 42 CFR 405.2401—405.2430.

   Visit—Face-to-face encounter between a clinic patient and a physician, physician assistant, nurse practitioner, nurse midwife, specialized nurse practitioner or visiting nurse for the purpose of receiving medical services. Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day and at a single location constitute a single visit, except for cases in which the patient, subsequent to the first encounter, suffers illness or injury requiring additional diagnosis or treatment.

Source

   The provisions of this §  1129.2 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial pages (58109) to (58110).

Cross References

   This section cited in 55 Pa. Code §  1129.53 (relating to payment policy for independent rural health clinics).

SCOPE OF BENEFITS


§ 1129.21. Scope of benefits for the categorically needy.

 Categorically needy recipients are eligible for rural health clinic services as defined at 42 CFR 440.20(b).

Source

   The provisions of this §  1129.21 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

§ 1129.22. Scope of benefits for the medically needy.

 Medically needy recipients are eligible for rural health clinic services as defined at 42 CFR 440.20(b).

Source

   The provisions of this §  1129.22 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

§ 1129.23. Scope of benefits for State Blind Pension recipients.

 State Blind Pension recipients are eligible for rural health clinic services as defined at 42 CFR 440.20(b).

Source

   The provisions of this §  1129.23 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

§ 1129.24. Scope of benefits for General Assistance recipients.

 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 §  1101.31(e) (relating to scope).

Source

   The provisions of this §  1129.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995.

PROVIDER PARTICIPATION


§ 1129.41. Participation requirements.

 (a)  In addition to the participation requirements established in Chapter 1101 (relating to general provisions), rural health clinics shall:

   (1)  Participate in the Medicare Program.

   (2)  Sign a provider agreement with the Department.

   (3)  Have an established fee schedule for billing third party and private payors.

 (b)  The rural health clinic shall submit a letter of application to the Bureau of Provider Relations, Office of Medical Assistance, Park Penn Building, Post Office Box 8029, Harrisburg, Pennsylvania, that includes:

   (1)  The name and address of the clinic.

   (2)  A list of the clinic owners and officers or members of the board of directors.

   (3)  The name and address of the physicians responsible for providing medical direction or supervision for the clinic.

   (4)  A list of rural health clinic personnel providing medical services, their days and hours of coverage per week and month.

   (5)  A description of the patient referral system.

   (6)  Copies of contracts or agreements between the clinic and licensed practitioners of all types relating to services provided by the clinic.

   (7)  A copy of the fee schedule used to charge private patients and third party payors.

   (8)  A statement indicating which practitioners, if any, are salaried by the rural health clinic to provide services outside the clinic.

   (9)  A copy of the cost report submitted to Medicare and a copy of the current or proposed budget or both.

Source

   The provisions of this §  1129.41 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

§ 1129.42. Ongoing responsibilities of providers.

 Ongoing responsibilities of providers are established in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1129.42 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

PAYMENT FOR RURAL HEALTH CLINIC SERVICES


§ 1129.51. General payment policy.

 (a)  Payment will be made for rural health clinic services rendered at the clinic, at a hospital or at the place of residence of the patient.

 (b)  Payment for rural health clinic services will be made on the basis of an all-inclusive visit fee established by the Medicare carrier. When the cost for a service provided by the clinic is included in the established visit fee, the practitioner rendering the service shall not bill the MA Program for it separately.

 (c)  An adjustment to the all-inclusive visit fee will be made when the Medicare carrier determines the difference, if any, between the total payment due the clinic and the total payment made during the reported period. The adjustment will be made as follows:

   (1)  If the clinic has been underpaid, the Department will make a lump sum payment for the amount due.

   (2)  If the clinic has been overpaid, the clinic shall make a lump sum payment to the Department for the amount due. A repayment plan not to exceed 1 year will be arranged by the Department at the request of the clinic if the Department is satisfied that a lump sum payment would impose severe financial hardship on the clinic.

Source

   The provisions of this §  1129.51 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; corrected August 14, 1987, effective December 24, 1983, 17 Pa.B. 3407. Immediately preceding text appears at serial page (117359).

§ 1129.52. Payment policy for provider rural health clinics.

 Payment will be made for rural health clinic services and other covered services provided by a provider rural health clinic on an all-inclusive fee basis as established by the Medicare carrier.

Source

   The provisions of this §  1129.52 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

§ 1129.53. Payment policy for independent rural health clinics.

 (a)  Payment will be made for rural health clinic services as defined in §  1129.2 (relating to definitions) provided by an independent rural health clinic on an all-inclusive visit fee basis as established by the Medicare carrier for rural health clinics.

 (b)  Covered service provided outside the scope of rural health clinic services as defined in §  1129.2 will only be paid by the Department according to the chapter governing payment for the specific service as set forth in this title.

Source

   The provisions of this §  1129.53 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

§ 1129.54. Payment conditions for various services.

 Payment for rural health clinic services is subject to the Medicare payment conditions set forth at 42 CFR 405.2401—405.2430.

Source

   The provisions of this §  1129.54 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

§ 1129.55. Limitations on payment.

 Rural health clinic services are subject to the payment limitations set forth at 42 CFR 405.2401—405.2430.

Source

   The provisions of this §  1129.55 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

§ 1129.56. Noncompensable services and items.

 A service not included in the all-inclusive visit fee as set by the Medicare carrier in accordance with 42 CFR 405.2401—405.2430 is noncompensable as a rural health service but may be compensable under other MA regulations.

Source

   The provisions of this §  1129.56 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

UTILIZATION CONTROL


§ 1129.71. Scope of claims 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).

Source

   The provisions of this §  1129.71 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.

ADMINISTRATIVE SANCTIONS


§ 1129.81. Provider misutilization.

 Providers determined to have billed for services inconsistent with MA Program regulations, to have provided services outside the scope of customary standards of medical practice, or to have otherwise violated the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1129.81 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.



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