55 Pa. Code § 1150.59 - PSR program

(a) Except as specified in subsection (b), a practitioner or facility shall request a PSR prior to the admission of a MA recipient to a general hospital, freestanding ambulatory surgical center or hospital short procedure unit for surgical or medical treatment.

(b) For the following type of admission, a practitioner is not required to request a PSR:

(1) An emergency admission as defined in § 1150.2 (relating to definitions).

(2) An urgent admission as defined in § 1150.2.

(3) A maternity admission as defined in § 1150.2.

(4) A newborn admission as defined in § 1150.2.

(5) The admission of a MA recipient who is also eligible for Medicare Part A benefits and for which the Department is responsible only for the deductible or coinsurance payment amounts.

(6) A recipient who is enrolled in a comprehensive health services plan or a capitated physician case management program.

(7) The admission of a MA recipient to a hospital based psychiatric unit, medical rehabilitation unit, drug and alcohol treatment/rehabilitation unit, freestanding rehabilitation hospital or freestanding drug and alcohol rehabilitation hospital as identified under Chapter 1163 (relating to inpatient hospital services) or to a freestanding psychiatric hospital as identified under Chapter 1151 (relating to private psychiatric hospital inpatient services).

(c) For an admission of a patient who is not eligible for MA at the time of the admission, a PSR is not required prior to the admission. If the facility is notified of the patient's eligibility for MA, or PSR will be conducted within 30 days of the notification to determine the compensability of the admission and the appropriate setting for the treatment for which the Department will make payment.

(d) The admission of a MA recipient to a hospital, freestanding ambulatory surgical center or hospital short procedure unit is subject to the Department's retrospective inpatient hospital review procedures as specified in Chapters 1126 and 1163 (relating to ambulatory surgical center services and hospital short procedure unit services; and inpatient hospital services); if exempt from the PSR program under subsection (b).

(e) If a practitioner or facility designates an admission as urgent or emergency but the Department determines, based on a review of the recipient's medical record and the medical data existing at the time of the admission, that the admission was elective, the Department will make payment equal to 50% of the MA approved reimbursement amount for services provided by the admitting practitioner or facility.

(f) The PSR requirements of this section are applicable for admission of a Commonwealth MA recipient regardless of whether the admission is to an in-State or out-of-State facility.

(g) Within 3 working days of receiving a place of service review request, the Department will do one of the following:

(1) Certify the request.

(2) Ask for additional information in order to certify the request as specified under subsection (h).

(3) Request a second opinion as specified under subsection (i).

(h) If the Department requests additional information under subsection (g), the provider will have 14 days to provide the Department with the information to have the PSR process completed. If the requested information is not received by the Department within 14 days, the provider shall reapply for certification.

(i) Before certification of PSR is completed, a second opinion shall be obtained if one of the following conditions exist:

(1) The procedure is on the mandatory second opinion list published by the Department.

(2) After review, the Department's physician questions the medical necessity of performing the procedure.

(j) If a second opinion is required under § 1150.60(a) (relating to second opinion program), a practitioner or facility may not request a PSR until he has documentation available, as specified in the provider handbook, that the recipient has obtained a second opinion.

(k) To be eligible for payment for an admission or procedure to a PSR, a facility or practitioner shall comply with the instructions in the provider handbook. Failure to comply with PSR procedures and applicable second opinion procedures in § 1150.60 will result in a payment equal to 50% of the MA approved reimbursement amount for services provided by the admitting practitioner and facility.

(l) Payment will not be made for an admission that occurs after the expiration date on the Department's letter notifying the facility, the recipient and the admitting practitioner that certification has been granted. If the admission has not occurred within the 60-day time period, the admitting practitioner or the facility is required to reapply for certification.

(m) The Department will make payment to a facility at the rate established for the certified site. If the setting utilized is different from the one originally certified and costs less, the Department will pay that lesser amount.

(n) If the Department determines that a procedure or treatment is noncompensable, as defined in § 1163.59 (relating to noncompensable services, items and outlier days), or certifies a procedure for a setting other than the one being proposed by the admitting practitioner, the admitting practitioner or the facility will be afforded the opportunity for an informal reevaluation by the Department's medical coordinator within 10 calendar days of the notification. A final decision by the medical coordination may be appealed by the recipient under Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings). A final decision by the medical coordinator may be appealed by the admitting practitioner or facility under § 1101.84 (relating to provider right of appeal). The evaluation process and request for appeal shall be completed within 30 days from the original PSR notification.

(o) When the certification is completed, the Department will send written notification to the physician, the facility and the recipient.

Notes

55 Pa. Code § 1150.59

The provisions of this § 1150.59 adopted August 11, 1989, effective immediately and apply retroactively to March 1, 1988, 19 Pa.B. 3391.

The provisions of this § 1150.59 issued under sections 443.1(1) and (4), 443.2(2)(ii) and 443.4 of the Public Welfare Code (62 P. S. §§ 443.1(1) and (4), 443.2(2)(ii) and 443.4).

This section cited in 55 Pa. Code § 1150.60 (relating to second opinion program).