CHAPTER 1145. CHIROPRACTORS’ SERVICES

GENERAL PROVISIONS

Sec.


1145.1.    Policy.

COVERED AND NONCOVERED SERVICES


1145.11.    Types of services covered.
1145.12.    Outpatient services.
1145.13.    Inpatient services.
1145.14.    Noncovered services.

SCOPE OF BENEFITS


1145.21.    Scope of benefits for the categorically needy.
1145.22.    Scope of benefits for the medically needy.
1145.23.    Scope of benefits for State Blind Pension recipients.
1145.24.    Scope of benefits for General Assistance recipients.

PROVIDER PARTICIPATION


1145.41.    Participation requirements.
1145.42.    Ongoing responsibilities of providers.

PAYMENT FOR CHIROPRACTORS’ SERVICES


1145.51.    General payment policy.
1145.53.    [Reserved].
1145.54.    Noncompensable services.

UTILIZATION REVIEW


1145.71.    Scope of claims review procedures.

ADMINISTRATIVE SANCTIONS


1145.81.    Provider misutilization.

Authority

   The provisions of this Chapter 1145 issued under sections 403, 443.3(2)(ii) and 509 of the Public Welfare Code (62 P. S. § §  403, 443.3(2)(ii) and 509), unless otherwise noted.

Source

   The provisions of this Chapter 1145 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105, unless otherwise noted.

Cross References

   This chapter cited in 55 Pa. Code §  1101.31 (relating to scope); 55 Pa. Code §  1101.95 (relating to conflicts between general and specific provisions); and 55 Pa. Code §  1163.51 (relating to general payment policy).

GENERAL PROVISIONS


§ 1145.1. Policy.

 The MA Program provides payment for specific chiropractors’ services rendered to eligible recipients by chiropractors enrolled as providers under the program. Payment for chiropractors’ 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.

Source

   The provisions of this §  1145.1 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105; 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 (117384).

COVERED AND NONCOVERED SERVICES


§ 1145.11. Types of services covered.

 The MA Program covers the following chiropractors’ services as specified in § §  1145.21—1145.23 (relating to scope of benefits):

   (1)  Evaluation by means of examination of the patient.

   (2)  Treatment by means of manual manipulation of the spine to adjust misaligned or displaced vertabrae.

Source

   The provisions of this §  1145.11 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

§ 1145.12. Outpatient services.

 Chiropractors’ services are covered when rendered in the chiropractors’ office, the home of the patient or in a skilled nursing or intermediate care facility.

Source

   The provisions of this §  1145.12 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

§ 1145.13. Inpatient services.

 Chiropractors’ services are not covered when rendered in a location in a hospital, including but not limited to a hospital emergency room, a hospital short procedure unit or a hospital clinic.

Source

   The provisions of this §  1145.12 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

§ 1145.14. Noncovered services.

 Payment will not be made for the following types of services regardless of where or to whom they are provided:

   (1)  Treatment other than manual manipulation of the spine to correct a subluxation.

   (2)  Physical therapy.

   (3)  Traction procedures.

   (4)  Physical examinations.

   (5)  Consultations.

Source

   The provisions of this §  1145.14 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

SCOPE OF BENEFITS


§ 1145.21. Scope of benefits for the categorically needy.

 Categorically needy recipients are eligible for covered chiropractors’ services.

Source

   The provisions of this §  1145.21 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

Cross References

   This section cited in 55 Pa. Code §  1145.11 (relating to types of services covered).

§ 1145.22. Scope of benefits for the medically needy.

 Medically needy recipients are eligible for covered chiropractors’ services.

Source

   The provisions of this §  1145.22 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

Cross References

   This section cited in 55 Pa. Code §  1145.11 (relating to types of services covered).

§ 1145.23. Scope of benefits for State Blind Pension recipients.

 State Blind Pension recipients are eligible for chiropractors’ services provided in the office or home.

Source

   The provisions of this §  1145.23 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

Cross References

   This section cited in 55 Pa. Code §  1145.11 (relating to types of services covered).

§ 1145.24. 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 §  1145.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995.

PROVIDER PARTICIPATION


§ 1145.41. Participation requirements.

 In addition to the participation requirements established in Chapter 1101 (relating to general provisions), chiropractors are required, as a condition of participation, to be licensed by the State Board of Chiropractic Examiners or, for drugless therapy, by the State Board of Medicine.

Source

   The provisions of this §  1145.41 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

§ 1145.42. Ongoing responsibilities of providers.

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

Source

   The provisions of this §  1145.42 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

PAYMENT FOR CHIROPRACTORS’ SERVICES


§ 1145.51. General payment policy.

 Payment is made for covered services provided by participating chiropractors subject to the conditions and limitations established in this section, §  1145.54 (relating to noncompensable services), and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule. Payment will not be made for compensable chiropractors’ service if payment is available from another public agency or insurance or health program. Chiropractors’ services shall be billed in the name of the chiropractor providing the service.

Source

   The provisions of this §  1145.51 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105; 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 (117387).

§ 1145.53. [Reserved].


Source

   The provisions of this §  1145.53 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105; reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (51261).

§ 1145.54. Noncompensable services.

 Payment will not be made to a chiropractor for the following:

   (1)  Orthotics.

   (2)  Prosthetics.

   (3)  Medical supplies.

   (4)  X-rays.

   (5)  Services not included in Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule. Payment will be made to approved medical suppliers for compensable items ordered by a chiropractor.

Source

   The provisions of this §  1145.54 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105; 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 (117387) to (117388).

Cross References

   This section cited in 55 Pa. Code §  1145.51 (relating to general payment policy).

UTILIZATION REVIEW


§ 1145.71. Scope of claims review procedures.

 Claims 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 §  1145.71 adopted July 25, 1980, effective September 1, 1980, 10 Pa.B. 3105.

ADMINISTRATIVE SANCTIONS


§ 1145.81. 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 chiropractic practice, or to have otherwise violated the standard set forth in the provider agreement, are subject to the sanctions imposed in Chapter 1101 (relating to general provisions).

APPENDIX A. [Reserved]



Source

   The provisions of this Appendix A reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (54221).



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