Control Number: 81-50
Subject: Definition of Physician Visit
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (3) (h), A (3) (o) 2 and 4, A (6) (a) and (b), and A (8)
Question:
1. What is the definition of “physician visit”?
2. Is a “physician visit” subject to co-payment?
3. Is each visit to a physician’s office subject to co-payment?
Answer:
1. A “physician visit” is defined as follows:
A face-to-face consultation for examination, diagnosis, treatment, or advice. It is a visit if the consultation described above is provided by a physician or by a nurse or other person acting under the physician’s supervision. The term “Physician” includes osteopathic physicians as well as M.D.s, but it does not include chiropractors.
Examples of a physician visit include, but are not limited to, the following:
a. Inhospital physician’s visits
b. Home, clinic, and office visits
c. Emergency treatment
d. Visit for medical consultation
e. Visit to specialist
f. Visit to podiatrist
g. Visit for primary medical care
h. Pre- and post-natal visits, if the physician charges separately for such visits in addition to the charge for delivery
i. Visit for outpatient mental health, alcoholism, and/or drug addiction
2. Yes.
3. No. It is not uncommon for a Beneficiary to visit a physician’s office and not see the physician. If the services the Beneficiary is receiving are on-going and routine in nature
Control No.: 81-50
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and do not require the direct supervision of a physician, such services are not subject to copayment. Examples of these routine services include, but are not limited to, the following:
a. Administration of B-12 injections for pernicious anemia
b. Administration of chemotherapy
c. Administration of radiation therapy
d. Administration of physical and speech therapy
e. Administration of allergy desensitization therapy (including the cost of materials, e.g. allergens for desensitization)
f. Blood pressure checks to monitor antihypertensive therapy