55 Pa. Code § 1163.451 - General payment policy
(a) The
payment policy established in this section and §§
1163.452-1163.458 applies to cost
reimbursed inpatient services provided by participating hospitals. The
Department will reimburse hospitals for the allowable costs they incur in
providing compensable cost reimbursed services to MA recipients. As a condition
of payment, those services shall meet the requirements of, and be provided
within, the limitations in this subchapter and Chapter 1101 (relating to
general provisions). The Department will assume responsibility for payment only
after other possible sources of payment are exhausted.
(b) The Department will reimburse hospitals
for cost items that it determines are allowable under §
1163.453 (relating to allowable
and nonallowable costs).
(c) Prior
to a settlement based on audited costs and charges, the Department will pay
hospitals an interim per diem rate for inpatient cost reimbursed services
provided to MA recipients under §
1163.452(a)
(relating to payment methods and rates).
(d) A final settlement will be made after the
hospital's cost report has been audited by the Department of the Auditor
General. The final settlement is subject to §
1163.452(c).
(e) The hospital shall submit invoices to the
Department in accordance with the instructions in the Provider
Handbook.
(f) The readmission of a
patient to a hospital within 24 hours of the patient's discharge from the same
hospital is not considered a new admission for MA purposes. It is considered a
continuation of the original admission.
(g) Payment for preadmission laboratory
tests, radiology services and other diagnostic services provided to patients
admitted to the hospital will be included in the payment for inpatient
services. The hospital may not submit a separate bill for these services. If
preadmission diagnostic services are provided to a scheduled inpatient who is
not admitted to the hospital as expected, the diagnostic services shall be
billed as outpatient services according to the fee schedule in Chapter 1150
(relating to MA Program payment policies) and the MA Program Fee
Schedule.
(h) 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 is 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.
(i) The
hospital may not seek reimbursement from an MA recipient if certification for
days of care is denied by the hospital's utilization review committee or the
Department through its Concurrent Hospital Review (CHR) process. If a patient
who has been discharged by a physician refuses to leave the hospital at the end
of a certified stay, the hospital may bill the recipient for days used beyond
the certified length of stay.
(j)
The hospital 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 it is not covered under
the MA Program.
(k) The hospital may
not bill the MA Program for services provided to a person who has applied for
MA benefits unless the CAO has notified the hospital that the person is
eligible for MA benefits.
(l) If a
hospital voluntarily terminates the provider agreement, payment for inpatient
hospital 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. Departmental payment will stop for services
provided on and after the effective date of the termination of the provider
agreement.
(m) If a patient is
admitted to the distinct part, medical rehabilitation or drug and alcohol
detoxification/rehabilitation unit of a general hospital from the emergency
room, the services provided in the emergency room shall be billed on the
inpatient invoice.
(n) Except as
specified in subsection (o), cost-reimbursed services and items provided to an
inpatient shall be billed as inpatient services.
(o) The following services and items may not
be billed as inpatient services:
(1) Direct
care services provided by salaried practitioners.
(2) Ambulance services for:
(i) Patients transferred from the emergency
room or clinic of a hospital to another hospital for admission.
(ii) Inpatients discharged from one hospital,
transferred by ambulance to another hospital and then admitted by the second
hospital.
Notes
The provisions of this § 1163.451 amended under section 443.1(1) of the Public Welfare Code (62 P. S. § 443.1(1)); and Articles I-XI and XIV of the Public Welfare Code (62 P. S. §§ 101-1411).
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