Section 443.6 - Reimbursement for certain medical assistance items and services(a) In order to receive reimbursement for items or services enumerated in subsection (b), the provider must secure authorization prior to actually providing the items or services. The request for prior authorization must justify to the reasonable satisfaction of the department the need for an item or service.(b) Payment for the following medical assistance items and services shall be made only after prior authorization has been secured:(1) Prostheses and orthoses.(2) Purchase of appliances or equipment if the appliance or equipment costs more than six hundred dollars ($600): Provided, however, That the department may require prior authorization for the purchase of specific appliances or equipment that costs less than six hundred dollars ($600).(3) Rental of medical appliances or equipment for a period in excess of six months: Provided, however, That the department may require prior authorization for the rental of medical appliances or equipment for a period of less than six months.(4) Oxygen and related equipment in the home unless a physician states that the physical surroundings in the home are suitable for the use of oxygen and that the recipient is adequately prepared and able to use the equipment.(5) Dental services as the department may provide, including but not necessarily limited to, dental prostheses and appliances.(6) Orthopedic shoes or other supportive devices for the feet when such shoes or devices are prescribed by a physician for the purpose of correcting or otherwise treating abnormalities of the feet or legs which cause serious detrimental medical effects.(7) Other items or services as the department may authorize by publication of notice in the Pennsylvania Bulletin.(c) The prior authorization requirements set forth in this section shall be applicable only to the extent that the items and services enumerated in subsection (b) are provided under the Pennsylvania Medical Assistance Plan. This section shall not be construed as mandating the provision of any item or service enumerated in this section.(d) The requirements of this section shall not apply in an emergency situation.(e) The department shall promulgate regulations to implement this section and shall establish a procedure for prior authorization. Such regulations may establish procedures for issuing prior authorization at whatever administrative level the department through the secretary deems appropriate. Appropriateness shall be determined by the secretary after hearings have been held and public input is received. Procedures adopted in accordance with this section shall provide authorization when appropriate, without undue delay. When no decision is made on a request to the department for covered services within twenty-one days of the date that the request is received by the department, the authorization shall be deemed approved. The department shall keep a record of those cases in which no decision is made within twenty-one days. The requirements of this section shall not apply in a medical emergency situation as defined by the department.
(f) Under no circumstances shall the department reimburse a provider for any medical services, procedures or drugs related to infertility therapy.(g) The department shall establish benefit packages for dental and pharmacy services for medical assistance recipients twenty-one years of age or older, and any exceptions to such benefit packages as the department determines are appropriate. Notwithstanding any other provision of law, including this section, during State fiscal year 2011-2012, the department shall establish such benefit packages, limits and exceptions thereto by publication of one or more notices in the Pennsylvania Bulletin. A notice shall describe the available benefit packages or limits and any exceptions thereto. The benefit packages, limits and exceptions thereto shall take effect as specified in the notice and remain in effect until changed by a subsequent notice issued on or before June 30, 2012, or thereafter by department regulation.1967, June 13, P.L. 31, No. 21, art. 4, § 443.6, added 1978, Sept. 26, P.L. 769, No. 146, § 1, effective in 60 days. Amended 1982, April 8, P.L. 231, No. 75, § 18, effective in 60 days; 1994, June 16, P.L. 319, No. 49, § 8, effective in 60 days; 2005, July 7, P.L. 177, No. 42, § 4, imd. effective; 2011, June 30, P.L. 89, No. 22, § 6, effective 7/1/2011.