CHAPTER 1144. CERTIFIED REGISTERED NURSE
PRACTITIONER SERVICES

GENERAL PROVISIONS

Sec.


1144.1.    Policy.
1144.2.    Definitions.

SCOPE OF BENEFITS


1144.21.    Scope of benefits for the categorically needy.
1144.22.    Scope of benefits for the medically needy.
1144.23.    Scope of benefits for State Blind Pension recipients.
1144.24.    Scope of benefits for General Assistance recipients.

PROVIDER PARTICIPATION


1144.41.    Participation requirements.
1144.42.    Ongoing responsibilities of providers.

PAYMENT FOR CERTIFIED REGISTERED NURSE
PRACTITIONER SERVICES


1144.51.    General payment policy.
1144.52.    Payment conditions.
1144.53.    Noncompensable services.

UTILIZATION CONTROL


1144.71.    Scope of claims review procedures.

ADMINISTRATIVE SANCTIONS


1144.81.    Provider misutilization.

Authority

   The provisions of this Chapter 1144 issued under sections 403(a) and (b) and 443.3(1) of the Public Welfare Code (62 P.S. § §  403(a) and (b) and 443.3(1)), unless otherwise noted.

Source

   The provisions of this Chapter 1144 adopted November 8, 1991, effective November 9, 1991 and apply retroactively to July 1, 1990, 21 Pa.B. 5259, unless otherwise noted.

Cross References

   This chapter cited in 55 Pa. Code §  1101.31 (relating to scope).

GENERAL PROVISIONS


§ 1144.1. Policy.

 The MA Program provides payment for specific medically necessary CRNP services rendered to eligible recipients by CRNPs enrolled as providers under the program. Payment for CRNP services is subject to this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and limitations established in the MA Program Fee Schedule.

§ 1144.2. Definitions.

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

   CRNP—Certified Registered Nurse Practitioner—A registered nurse licensed in this Commonwealth who is certified by the State Board of Nursing and State Board of Medicine in a particular clinical specialty area who, while functioning in the expanded role as a professional nurse, performs acts of medical diagnosis or prescription of medical therapeutic or corrective measures in collaboration with and under the direction of a physician licensed to practice medicine in this Commonwealth.

   CRNP services—Care provided within the scope of a CRNP professional practice and licensure.

   Direction—Physician supervision of the CRNPs performance of medical acts as defined in 49 Pa. Code §  21.251 (relating to definitions).

   Protocol—The written treatment instructions prepared by the supervising physician for use by the CRNP.

Cross References

   This section cited in 55 Pa. Code §  1144.42 (relating to ongoing responsibilities of providers).

SCOPE OF BENEFITS


§ 1144.21. Scope of benefits for the categorically needy.

 Categorically needy recipients are eligible for medically necessary CRNP services compensable under the MA Program.

§ 1144.22. Scope of benefits for the medically needy.

 Medically needy recipients are eligible for medically necessary CRNP services compensable under the MA Program.

§ 1144.23. Scope of benefits for State Blind Pension recipients.

 State Blind Pension recipients are not eligible for CRNP services unless they are also either categorically or medically needy.

§ 1144.24. 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 §  1144.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995.

PROVIDER PARTICIPATION


§ 1144.41. Participation requirements.

 Participation requirements are established in § §  1101.41—1101.43 (relating to participation).

§ 1144.42. Ongoing responsibilities of providers.

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

 (b)  In addition, CRNPs shall furnish the following to the Department:

   (1)  The identity of the physician providing medical direction as defined in §  1144.2 (relating to definitions).

   (2)  The established physician/CRNP protocols.

PAYMENT FOR CERTIFIED REGISTERED NURSE
PRACTITIONER SERVICES


§ 1144.51. General payment policy.

 Payment is made for compensable CRNP services provided by participating CRNPs subject to the conditions and limitations established in this chapter. Chapters 1101 and 1150 (relating to general provisions; and the MA Program payment policies) and the MA Program Fee Schedule.

§ 1144.52. Payment conditions.

 Payment will be made to a CRNP for services furnished if the following conditions are met:

   (1)  The CRNP, unless qualifying for the exception in paragraph (3), does not have a financial arrangement to provide the services as an employe of or is not under contract to an enrolled medical service provider or practitioner.

   (2)  The services billed to the Department are furnished by the CRNP in collaboration with and under the direction of a physician licensed to practice medicine in this Commonwealth.

   (3)  An exception to the payment condition in paragraph (1) has been established for the CRNP employed by an enrolled MA entity unable to be reimbursed for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screens. In this case, the CRNP may enroll with the Department, with the employer recognized as the payee.

§ 1144.53. Noncompensable services.

 Payment will not be made for the following:

   (1)  Procedures not listed in the MA Program fee schedule or precluded by Chapter 1150 (relating to the MA Program payment policies).

   (2)  Services and procedures furnished by the CRNP for which payment is made to an enrolled medical service provider or practitioner.

   (3)  Services and procedures for which payment is available through other public agencies or private insurance plans as described in §  1101.64 (relating to third-party medical resources (TPR)).

   (4)  The same service and procedure furnished to the same recipient by a CRNP and physician, with whom the CRNP has protocols, on the same day.

UTILIZATION CONTROL


§ 1144.71. 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).

ADMINISTRATIVE SANCTIONS


§ 1144.81. 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 in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).



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