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Title: Section 533.3 - State reimbursement.

533.3 State reimbursement. (a) Basis for reimbursement. Reimbursement for physicians' services for which a maximum reimbursable allowance has been established in this Part shall be based upon payments actually made. However, reimbursement shall not be available for amounts paid in excess of the maximum reimbursable allowance prescribed nor for services not included in Part 505 of this Subchapter.

(1) If a physicians' service or procedure for which no maximum reimbursable allowance has been established in this Part is necessarily rendered, reimbursement shall be based upon the expenditures actually made therefor, in accordance with applicable regulations of the department.

(2) If, in accordance with the accepted practice, a physician's service or a procedure hereinafter listed in this Part is commonly carried out as an integral part of the total service, only the value of the principal service or procedure shall be the basis for reimbursement. When such a procedure is carried out as a separate entity not immediately related to other services, reimbursement shall be based upon the fee for the particular service or procedure.

(i) When a special procedure is performed during a medical emergency when the physician is rendering intensive care, items 9072 and 9073, for which there would be a separate allowance, reimbursement shall be available for the higher of the two allowances, i.e., the allowance for service or allowance for time.

(3) If immunization is administered at the time of an office visit, reimbursement will be based upon the immunization fee in addition to the fee appropriate for the level of services provided during an office visit.

(4) Charges for special diagnostic procedures which are not considered to be a routine part of a physician's or consultant's examination (e.g.) complete blood count, diagnostic X-ray, lumbar puncture) are reimbursable in addition to the physician's usual office or home visit fee.

(b) Intensive or unusual services. (1) For intensive or unusual medical treatment rendered to a patient who has an illness of such serious, critical or unusual nature as to require time and study far beyond normal limits, a fee in excess of that listed in the fee schedule may be approved by the appropriate authority. Decision shall be based on the facts of the case supplied by the attending physician.

(2) When a special procedure is performed during a medical emergency for which there would be a separate fee, the physician shall receive the higher of the two fees (fee for special service or fee for time).

(c) Services by more than one physician. When warranted by the necessity of supplemental skills, reimbursement shall be available for expenditures for services rendered to a patient by two or more physicians.

(d) Multiple visits. If an Individual patient is necessarily seen on more than one occasion during a single day, expenditures for each such visit shall be subject to reimbursement.

(e) Drugs and supplies. Expenditures made by a social services district for necessary drugs, materials and supplies provided by a physician, where separate payment therefore is made in accordance with the local medical plan, shall be subject to reimbursement in accordance with applicable regulations of the department.

(f) Consultation fees. (1) Reimbursement for consultation fee expenditures shall be available only when an examination is made by an accredited specialist, within the scope of his specialty, upon request of the responsible physician who is treating the medical problem for which consultation is required. The responsible physician shall certify that he requested such consultation and that it was incident to and necessary for his further treatment of the patient.

(2) When the consultant physician assumes the continuing care of the patient, any subsequent services rendered by him shall not be considered as consultation, and the established visit fees shall apply.

(g) Specialists' fees. Reimbursement for a specialist's fee shall be available only where the services rendered are within the field of his specialty. Services performed by a specialist outside his field of specialization shall be charged in accordance with the general practitioner's fee schedule.

(h) Complete physical examination. Reimbursement for expenditures for a complete physical examination shall be available only when such examination has prior approval by the appropriate authority except when such examination is required in an emergency.

(i) Telephone calls. The services rendered by a physician directly to a patient over the telephone are not reimbursable. Long distance calls by a physician to another physician who has previously attended the patient or to a hospital or other medical facility to obtain additional medical information are reimbursable.



VOLUME C (Title 18)