1. (a) Reimbursement for organized outpatient clinic services shall be the usual charges made to the general public not to exceed the maximum reimbursement rates listed in this section.

2. (b) Organized outpatient clinics with surgical facilities, as defined in Health and Safety Code Section 1204(b), shall be reimbursed as follows.

   1. (1) Payment for surgical procedures may be made either directly to the clinic or separately to the clinic, physician or dentist for the services provided by each provider.

      1. (A) Reimbursement for clinic services shall not exceed the amounts listed in (3).
      2. (B) Reimbursement for physician or dental services, normally provided in an office setting as determined by the Department, shall not exceed 80 percent of the maximum allowed under Section 51509.1(e), or Section 51506, as appropriate.
      3. (C) Reimbursement for physician or dental services, not normally provided in an office setting as determined by the Department, shall not exceed the full amount allowed under Section 51509.1(e), or Section 51506, as appropriate.

   2. (2) Payment for nonsurgical procedures shall:

      1. (A) Be made directly to the clinic.
      2. (B) Not exceed the amounts payable in accordance with Section 51509.1(e).

   3. (3) Maximum reimbursement rates for clinic services, when surgery is provided, shall be as follows:

      Procedure Code

      Maximum Allowance

      Z7500

      Use of examining or treatment room

      $21.66

      Z7504

      Use of cast room

      31.49

      Z7506

      Use of operating room or cystoscopic room--first hour

      92.83

      Z7508

      first subsequent half hour

      37.13

      Z7510

      second subsequent half hour

      37.13

      maximum charges

      185.65

      Z7512

      Use of recovery room

      16.59

      Z7514

      Payment for room and board and general nursing care for stays of less than 24 hours, including ordinary medication

      37.13

      Z7612

      Unlisted services

      By Report

3. (c) Community clinics and free clinics, as defined in Health and Safety Code Section 1204(a), and county operated organized outpatient clinics not subject to reimbursement as a hospital outpatient department under Section 51509, shall be reimbursed directly.

   1. (1) Reimbursement for physician services and the services of nonphysician medical practitioners shall be made in accordance with the provisions of Section 51503.
   2. (2) Maximum reimbursement rates for other services shall not exceed the maximum payment under the program for the same services by individual providers.
   3. (3) Reimbursement for take-home drugs dispensed by clinics that have obtained permits pursuant to Business and Professions Code Section 4063 et seq. shall not exceed the amounts payable for drug ingredient cost under Section 51513. No dispensing fee or markup shall be paid.

4. (d) Rural health clinics, as defined in Section 51115.5, shall maintain adequate financial and statistical records to allow determination of the cost of covered services furnished to Medi-Cal beneficiaries.

   1. (1) Reimbursement for rural health clinic services provided by a rural health clinic that is an integral part of a hospital and is operating under common licensure with other departments of the hospital shall be on the basis of reasonable cost, as specified in Section 450.30(a)(10)(i), Title 42, Code of Federal Regulations.
   2. (2) Reimbursement for rural health clinic services provided by all other rural health clinics shall be on the basis of an interim cost-reimbursement rate per clinic visit established for the clinic under the principles established in Title 42, Code of Federal Regulations, Section 450.30 (a) (10) (ii) or (iii) (A). These interim reimbursements shall be subjected to reconciliation to reasonable cost and any screening guidelines or tests of reasonableness established by the Health Care Financing Administration.

5. (e) Organized outpatient clinics, not qualifying under (b), (c) or (d), shall be reimbursed directly.

   1. (1) Reimbursement for physician services and the services of nonphysician medical practitioners shall be made in accordance with the provisions of Section 51503.
   2. (2) Maximum reimbursement rates for other services shall not exceed the maximum payment under the program for the same services by individual providers.

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code; and Section 208, Health and Safety Code. Reference: Sections 14105, 14132 and 14132.1, Welfare and Institutions Code; Statutes of 1985, Chapter 111, Items 4260-106-001 and 890; Statutes of 1998, Chapter 324, Items 4260-101-0001 and 0890; Statutes of 1999, Chapter 50, Items 4260-101-0001 and 4260-101-0890; Section 4063.7, Business and Professions Code; and Statutes of 2000, Chapter 52, Items 4260-101-0001 and 0890.

History

1. Amendment of subsections (b)(3) and (c)(1) filed 8-1-84 as an emergency; effective upon filing (Register 84, No. 31). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-84. For prior history, see Register 81, No. 52.

2. Certificate of Compliance transmitted to OAL 11-27-84 and filed 12-27-84 (Register 84, No. 52).

3. Amendment of subsections (b)(3) and (c)(1) filed 8-1-85 as an emergency; effective on filing (Register 85, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-85.

4. Certificate of Compliance transmitted to OAL 11-20-85 and filed 12-27-85 (Register 85, No. 52).

5. Amendment of subsection (c)(1) filed 5-9-88 as an emergency; operative 5-15-88 (Register 88, No. 20). Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 9-12-88.

6. Certificate of Compliance transmitted to OAL 9-1-88 and filed 10-3-88 (Register 88, No. 42).

7. Amendment of subsection (b)(3) filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.

8. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).

9. New subsection (c)(3) and amendment of Note filed 1-6-94; operative 2-7-94 (Register 94, No. 1).

10. Amendment of subsection (b)(1)(B) filed 7-21-98 as an emergency; operative 7-27-98 (Register 98, No. 30). A Certificate of Compliance must be transmitted to OAL by 11-24-98 or emergency language will be repealed by operation of law on the following day.

11. Editorial correction of History 10 (Register 99, No. 2).

12. Certificate of Compliance as to 7-21-98 order transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No. 2).

13. Amendment of section and Note filed 3-1-99 as an emergency; operative 3-1-99 (Register 99, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-29-99 or emergency language will be repealed by operation of law on the following day.

14. Reinstatement of section as it existed prior to 3-1-99 emergency amendment by operation of Government Code section 11346.1(f) (Register 99, No. 33).

15. Amendment of section and Note filed 8-10-99 as an emergency; operative 8-10-99 (Register 99, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-8-99 or emergency language will be repealed by operation of law on the following day.

16. Certificate of Compliance as to 8-10-99 order transmitted to OAL 12-2-99 and filed 1-13-2000 (Register 2000, No. 2).

17. Amendment of subsection (e)(1) and amendment of Note filed 11-13-2000 as an emergency; operative 11-13-2000 (Register 2000, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-13-2001 or emergency language will be repealed by operation of law on the following day.

18. Certificate of Compliance as to 11-13-2000 order transmitted to OAL 3-13-2001 and filed 4-4-2001 (Register 2001, No. 14).

19. Amendment of subsections (c)(1) and (e)(1), new subsection (f) and amendment of Note filed 7-16-2002; operative rates for services provided on or after 8-1-2000 pursuant to Stats. 2000, c. 52, Items 4260-101-0001 and 0890 (Register 2002, No. 29).

20. Certificate of Compliance as to 7-16-2002 order, including repealer of subsection (f), transmitted to OAL 11-12-2002 and filed 12-24-2002 (Register 2002, No. 52).