Limitations on Services
Within each calendar year each recipient is limited to no more than a total of 14 physician visits in offices, hospital outpatient settings, nursing facilities, rural health clinics or Federally Qualified Health Centers. Visits not counted under this benefit limit will include, but not be limited to, visits
for: EPSDT, prenatal care, postnatal care, and family planning. Physicians services provided in a hospital outpatient setting that have been certified as an emergency do not count against the physician benefit limit of 14 per calendar year. If a patient receives ancillary services in a doctor’s office,
by the physician or under his/her direct supervision, and the doctor submits a claim only for the ancillary services but not for the office visit, then the services provided will not be counted as a visit.
Office visits are limited to one per day per recipient per provider. For purposes of this limitation, physicians within the same group are considered a single provider. Annual office visit benefit limits are 14 office visits per calendar year.
For further information regarding outpatient maintenance dialysis and ESRD, refer to Chapter 35, Renal Dialysis Facility.
A new patient office visit codes shall not be paid to the same physician or same group practice for a recipient more than once in a three-year period.
