55 Pa. Code § 1150.61 - Guidelines for fee schedule changes

(a) Notice will be published in the Pennsylvania Bulletin when fees are changed and when procedures, services or items are added to, or deleted from, the MA Program Fee Schedule.

(b) Procedures, services and items requested by providers, the MA Advisory Committee, the Senate Public Health and Welfare Committee, and the House Health and Welfare Committee, the Department or other interested parties may be added to the MA Program Fee Schedule on the basis of the following:

(1) The procedure, service or item is determined to be medically necessary by the Department after consultation with the MA Advisory Committee, other third-party payors and the Department's medical consultants.

(2) The procedure, service or item is accepted as a standard practice by the medical community.

(3) The procedure, service or item is not prohibited by Federal or State statute or regulation.

(c) Individual procedures, services or items will be deleted from the MA Program fee schedule, in consideration of recommendations by the MA Advisory Committee, and on the basis of one or more of the following:

(1) The procedure, service or item is replaced by a generally accepted new technique or more definitive procedure.

(2) The procedure, service or item is no longer accepted as a standard practice by the medical community.

(3) The MA Advisory Committee recommends to the Department that a procedure, service or item should be deleted from the fee schedule as not medically necessary.

(d) The following guidelines will be considered in establishing a prior authorization requirement for a procedure, service or item to avoid misutilization:

(1) Article IV(f) and section 509 of the Public Welfare Code (62 P. S. §§ 441.1-447 and 509).

(2) Chapter 1101 (relating to general provisions) and 42 CFR Part 440 (relating to services; general provisions).

(3) Usage and quality of the procedure, service or item.

(4) To the extent consistent with paragraphs (1)-(3), policies followed by Medicare, other third-party payors, provider associations, other state Medicaid agencies and Federal agencies.

Notes

55 Pa. Code § 1150.61

The provisions of this § 1150.61 adopted September 30, 1988, effective 10/1/1988, 18 Pa.B. 4418.