55 Pa. Code § 1151.41 - General payment policy
(a)
This chapter and Chapter 1101 (relating to general provisions) govern payment
for inpatient psychiatric facility services.
(b) If a recipient is readmitted to an
inpatient psychiatric facility within 24 hours of the recipient's discharge
from the same facility, it will not be considered a new admission for MA
purposes, but rather a continuation of the original admission.
(c) If a recipient is admitted to an
inpatient psychiatric facility and discharged the same calendar day, the
Department will do the following:
(1) Pay
one-half of the per diem rate determined by the Department for the facility
under §
1151.46 (relating to payment rate
calculations for Fiscal Years 1993-94 and 1994-95).
(2) Count the stay as one-half of an
inpatient day for cost settlement purposes, for facilities which are subject to
cost settlement.
(d)
Payment for preadmission laboratory tests, radiology services and other
diagnostic services provided to patients admitted to an inpatient psychiatric
facility will be included in the payment for inpatient services. If
preadmission diagnostic services are provided to a patient who is scheduled to
be admitted but who is not admitted to the inpatient psychiatric facility as
expected, the diagnostic services shall be billed as outpatient services
according to Chapter 1150 (relating to MA Program payment policies) and the MA
Program fee schedule.
(e) An
inpatient psychiatric facility may not seek reimbursement from an MA recipient
if either the facility's utilization review committee or the Department,
through its Concurrent Hospital Review process, denies certification for that
recipient's days of care. If a patient who has been discharged by a physician
refuses to leave the facility at the end of a certified stay, the facility may
bill the recipient for days used beyond the length of stay certified by the
Department or the facility's utilization review committee.
(f) The inpatient psychiatric facility may
bill an MA recipient for days of care related to a noncovered service if the
recipient was informed prior to receiving the service that the particular
service and the inpatient care relating to the service were not covered under
the MA Program.
(g) The inpatient
psychiatric facility may not bill the MA Program for services provided to a
person who has applied for MA benefits unless the CAO has notified the MA
facility that the person is eligible for MA benefits.
(h) If a private psychiatric hospital, or the
general hospital of which the psychiatric unit is a part, voluntarily
terminates the provider agreement, payment for inpatient services continues for
MA patients admitted prior to the date on which the facility announced its
intent to withdraw from the program, until the effective date of the
termination. The Department will not pay for services provided on or after the
effective date of the termination of the provider agreement.
(i) The Department will continue to make
payment to a facility affected by a strike for patients temporarily transferred
to a facility licensed to provide the required care. If the facility to which
the patient is transferred has a per diem rate which is different from that of
the transferring facility, the transferring facility will be reimbursed the
lower rate. The facility shall immediately notify the Office of Medical
Assistance Programs in writing of an impending strike and follow with a listing
of MA patients and the facility to which they are to be transferred.
(j) For payment to be made for laboratory
tests and other diagnostic procedures, the studies shall be related to the
patient's condition and be specifically ordered in writing for the particular
patient by the attending physician or other licensed practitioner who is
responsible for determining the diagnosis or treatment of that patient. In
emergency situations, an exception will be made to the requirement that studies
be specifically ordered in writing if the test or procedure is necessary to
prevent the death or serious impairment of the health of the recipient. Payment
will not be made for diagnostic services performed pursuant to a preprinted
regimen.
(k) As part of the
discharge planning process, the inpatient psychiatric facility shall refer the
patient to the local mental health program in the patient's county of
residence.
Notes
The provisions of this § 1151.41 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201 and 443.1(1)).
This section cited in 55 Pa. Code § 1151.41a (relating to clarification of the term "in writing"-statement of policy).
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