55 Pa. Code § 1101.33 - Recipient eligibility
(a)
Verification of eligibility. The County Assistance Office
determines whether or not an applicant is eligible for MA services. If the
applicant is determined to be eligible, the Department issues Medical Services
Eligibility (MSE) cards that are effective from the first of the month through
the last day of the month. Providers are responsible for checking the effective
dates on the MSE card and for making sure that services are furnished to a
person named on the card. The Department may not pay providers for services the
provider rendered to persons ineligible on the date of service unless there is
specific provision for the payment in the provider regulations. If the provider
notes any discrepancies, he should call the recipient's County Assistance
Office to verify eligibility.
(b)
Services restricted to a single provider. Providers are
responsible for checking the recipient's MSE card and other forms of
notification sent to the provider by the Department, to verify that the
recipient has not been restricted to obtaining the service from a single
provider. The Department may not pay for a restricted service rendered by a
provider other than the one to which a recipient has been restricted unless it
was furnished in response to an emergency situation. Reference should be made
to §
1101.91(b)
(relating to recipient misutilization and abuse).
(c)
Other resources. The MSE
card lists any other medical coverage a recipient has of which the Department
may be aware. However, the provider has the responsibility of attempting to
identify and utilize all of the recipient's medical resources before billing
the Department as described in §
1101.64 (relating to third-party
medical resources (TPR)).
Notes
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