55 Pa. Code § 1223.53

Current through Register Vol. 54, No. 24, June 15, 2024

Section 1223.53 - Limitations on payment

Payment is subject to the following service limitations:

(1) One 15-minute clinic visit per day provided an eligible recipient. Payment will be made for only one of the following if more than one compensable service is provided in one 24-hour period: methadone maintenance clinic visit, chemotherapy clinic visit, drug-free clinic visit or opiate detoxification clinic visit. If psychotherapy is provided on the same day as a clinic visit, payment will be made only for the psychotherapy.

(2) Seven methadone maintenance clinic visits per patient per week for as long as the patient requires methadone maintenance as determined by his physician and documented in the patient's medical record.

(3) Forty-two opiate detoxification clinic visits per patient per 365-day period for the purpose of outpatient, ambulatory opiate detoxification.

(4) A total of three chemotherapy or drug-free clinic visits per patient in a 30-day period for patients not on methadone maintenance or receiving opiate detoxification.

(5) Eight total hours of psychotherapy per patient per 30-day period. This total applies to all psychotherapy: individual, family and group.

(6) One psychiatric evaluation or comprehensive medical evaluation per patient per 365-day period. Either the psychiatric evaluation or the comprehensive medical evaluation may be billed in a 365-day period; payment will only be made for one evaluation in one 365-day period.

(7) One comprehensive diagnostic psychological evaluation or up to an $80 maximum worth of individual psychological or intellectual evaluations per patient per 365-day period.

55 Pa. Code § 1223.53

The provisions of this § 1223.53 amended February 26, 1982, effective 3/15/1982, 12 Pa.B. 837; amended September 30, 1988, effective 7/29/1987, 18 Pa.B. 4423; amended August 9, 1991, effective immediately and apply retroactively to January 1, 1990, 21 Pa.B. 3511.

The provisions of this § 1223.53 amended under sections 403(a) and (b), 443.3(1) and 509 of the Public Welfare Code (62 P. S. §§ 403(a) and (b), 443.3(1) and 509).