55 Pa. Code § 1187.101 - General payment policy
(a)
Payment for nursing facility services will be subject to the following
conditions and limitations:
(1) This chapter
and Chapter 1101 (relating to general provisions).
(2) Applicable State statutes.
(3) Applicable Federal statutes and
regulations and the Commonwealth's approved State Plan.
(b) Payment will not be made for nursing
facility services at the MA per diem rate if full payment is available from
another public agency, another insurance or health program or the resident's
resources.
(c) Payment will not be
made in whole or in part for nursing facility services provided during a period
in which the nursing facility's participation in the MA Program is
terminated.
(d) Claims submitted for
payment under the MA Program are subject to the utilization review procedures
established in Chapter 1101. In addition, the Department will perform the
reviews specified in this chapter for controlling the utilization of nursing
facility services.
Notes
This section cited in 55 Pa. Code § 1187.21 (relating to nursing facility participation requirements).
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