reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR OUTPATIENT BEHAVIORAL HEALTH SERVICES › Section 1153.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment is made for medically necessary professional medical and psychiatric
				  services provided by or under the supervision and direction of a psychiatrist
				  by participating psychiatric outpatient clinics and psychiatric partial
				  hospitalization outpatient facilities subject to the conditions and limitations
				  established in this chapter and Chapters 1101 and 1150 (relating to general
				  provisions; and MA Program payment policies) and the MA Program Fee
				  Schedule.
(b) The Department will
				  publish procedures for the use of tele-behavioral health to provide compensable
				  psychiatric outpatient clinic or psychiatric partial hospitalization services
				  in the
Pennsylvania Bulletin
.
(c) Payment will not be made for a
				  compensable psychiatric outpatient clinic, MMHT or psychiatric partial
				  hospitalization outpatient service if payment is available from another public
				  agency or another insurance or health program.
The provisions of this §
												1153.51 amended under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR OUTPATIENT BEHAVIORAL HEALTH SERVICES › Section 1153.53 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is subject to the following limitations:
(1) Psychiatric partial hospitalization
				  outpatient service is provided for at least 3 hours per 24-hour
				  period.
(2) The partial
				  hospitalization outpatient service fees listed in the MA Program Fee Schedule
				  include payment for all services rendered to the individual during a
				  psychiatric partial hospitalization outpatient session. Separate billings for
				  individual services are not compensable.
(3) Partial hospitalization outpatient
				  facilities licensed for adult programs will be reimbursed at the adult rate,
				  regardless of the age of the individual receiving treatment.
(4) Partial hospitalization outpatient
				  facilities licensed as children and youth programs will be reimbursed at the
				  child rate only when the individual receiving treatment is under 15 years of
				  age.
(5) Family psychotherapy and
				  collateral family psychotherapy are compensable for only one person per
				  session, regardless of the number of family members who participate in the
				  session or the number of participants who are eligible for
				  psychotherapy.
(6) MMHT group
				  therapy shall be provided only in an approved community-based site as specified
				  in the treatment plan to individuals receiving MMHT services from the
				  psychiatric outpatient clinic.
The provisions of this §
												1153.53 amended under sections
						201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Human Services Code
						(62
						P. S. §§
													201(2),
						403(b), 443.1, 443.3, 443.6,
						448 and 454).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR OUTPATIENT BEHAVIORAL HEALTH SERVICES › Section 1153.53a - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
The provisions of this §
												1153.53a reserved under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR OUTPATIENT BEHAVIORAL HEALTH SERVICES › Section 1153.54 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for items and services not listed
					 as compensable in the MA Program Fee Schedule.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › UTILIZATION REVIEW › Section 1153.71 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
					 subject to the utilization review procedures established in Chapter 1101
					 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › ADMINISTRATIVE SANCTIONS › Section 1153.81 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
					 inconsistent with MA Program regulations, to have provided services outside the
					 scope of customary standards of medical practice, or to have otherwise violated
					 the standards set forth in the provider agreement, are subject to the sanctions
					 described in Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › GENERAL PROVISIONS › Section 1155.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Medical
				  Assistance (MA) Program provides payment for intensive behavioral health
				  services (IBHS) when the services are medically necessary and provided to
				  eligible children, youth or young adults with a behavioral health diagnosis by
				  licensed IBHS agencies enrolled in the MA Program as providers under this
				  chapter.
(b) Payment for IBHS is
				  subject to the provisions in this chapter, Chapter 1101 (relating to general
				  provisions), the limitations in Chapter 1150 (relating to MA Program payment
				  policies) and the MA Program fee schedule.
(c) This chapter does not apply to individual
				  licensed practitioners or group arrangements of licensed practitioners that
				  bill only for services provided directly by the licensed
				  practitioners.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › SCOPE OF BENEFITS › Section 1155.11 - Scope of benefits

Current through Register Vol. 54, No. 28, July 13, 2024
Children, youth or young adults with a behavioral health
					 diagnosis are eligible to receive covered IBHS.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PROVIDER PARTICIPATION › Section 1155.21 - Participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements in Chapter
					 1101 (relating to general provisions), an IBHS agency shall meet the following
					 requirements to participate in the MA Program:
(1) Be licensed as an IBHS agency in
				  accordance with Chapters 20 and 5240 (relating to licensure or approval of
				  facilities and agencies; and intensive behavioral health services).
(2) Enter into a written provider agreement
				  with the Department.
(3) Be
				  enrolled in the MA Program by the Department.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PROVIDER PARTICIPATION › Section 1155.22 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Ongoing responsibilities of IBHS agencies
				  are in Chapters 1101 and 5240 (relating to general provisions; and intensive
				  behavioral health services).
(b)
				  Recordkeeping requirements for IBHS agencies are in §§
										1101.51(e),
				  5240.41 and
				  5240.42 (relating to ongoing
				  responsibilities of providers; individual records; and agency
				  records).
(c) An IBHS agency shall
				  notify the Department of a change in name or address.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PAYMENT FOR INTENSIVE BEHAVIORAL HEALTH SERVICES › Section 1155.31 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Except as provided in subsections (b)-(d), payment is made to a licensed IBHS
				  agency for medically necessary IBHS provided by qualified individuals under the
				  supervision and direction of a clinical director that meets the qualifications
				  in §
										5240.12(b) or
				  §
										5240.81(b)
				  (relating to staff qualifications; and staff qualifications for ABA services),
				  subject to the conditions and limitations in this chapter, Chapters 1101 and
				  1150 (relating to general provisions; and MA Program payment policies) and the
				  MA Program fee schedule.
(b)
				  Payment will be made to an IBHS agency that complies with Chapter 5240
				  (relating to intensive behavioral health services) and holds an outpatient
				  psychiatric clinic, a psychiatric partial hospitalization program or a
				  family-based mental health license issued by the Department as of October 19,
				  2019, until the agency's license expires.
(c) Payment will be made to an unlicensed
				  IBHS agency that complies with Chapter 5240 and is approved to provide
				  behavioral health rehabilitation services as of October 19, 2019, for 1 year
				  after promulgation of this chapter.
(d) Payment will be made to an unlicensed
				  IBHS agency that complies with Chapter 5240 and is approved to provide ABA
				  services as of October 19, 2019, for 180 days after promulgation of this
				  chapter.
(e) Payment will not be
				  made for a compensable IBHS if payment is available through a third party.
				  Providers shall comply with §
										1101.64 (relating to third-party
				  medical resources (TPR)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PAYMENT FOR INTENSIVE BEHAVIORAL HEALTH SERVICES › Section 1155.32 - Payment conditions for individual services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment will be made to a licensed IBHS
				  agency for individual services if the following conditions are met:
(1) There is a written order for services
				  based on a face-to-face interaction with the child, youth or young adult that
				  meets the following:
(i) Written within 12
				  months prior to the initiation of IBHS.
(ii) Written by a licensed physician,
				  licensed psychologist, certified registered nurse practitioner or other
				  licensed professional whose scope of practice includes the diagnosis and
				  treatment of behavioral health disorders and the prescribing of behavioral
				  health services, including IBHS.
(iii) Includes a behavioral health disorder
				  diagnosis listed in the most recent edition of the DSM or ICD.
(iv) Orders one or more IBHS for the child,
				  youth or young adult and includes the following:
(A) The clinical information to support the
				  medical necessity of the service ordered.
(B) The maximum number of hours of each
				  service per month.
(C) The settings
				  where services may be provided.
(D)
				  The measurable improvements in the identified therapeutic needs that indicate
				  when services may be reduced, changed or terminated.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PAYMENT FOR INTENSIVE BEHAVIORAL HEALTH SERVICES › Section 1155.33 - Payment conditions for ABA services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment will be made to a licensed IBHS
				  agency for ABA services if the following conditions are met:
(1) There is a written order for ABA services
				  based on a face-to-face interaction with the child, youth or young adult that
				  meets the following:
(i) Written within 12
				  months prior to the initiation of ABA services.
(ii) Written by a licensed physician,
				  licensed psychologist, certified registered nurse practitioner or other
				  licensed professional whose scope of practice includes the diagnosis and
				  treatment of behavioral health disorders and the prescribing of behavioral
				  health services, including IBHS.
(iii) Includes a behavioral health disorder
				  diagnosis listed in the most recent edition of the DSM or ICD.
(iv) Orders ABA services for the child, youth
				  or young adult and includes the following:
(A)
				  The clinical information to support the medical necessity of each ABA service
				  ordered.
(B) The maximum number of
				  hours of each ABA service per month.
(C) The settings where ABA services may be
				  provided.
(D) The measurable
				  improvements in targeted behaviors or skill deficits that indicate when
				  services may be reduced, changed or terminated.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PAYMENT FOR INTENSIVE BEHAVIORAL HEALTH SERVICES › Section 1155.34 - Payment conditions for group services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment will be made to a licensed IBHS
				  agency for group services if the following conditions are met:
(1) There is a written order for group
				  services that meets the requirements of §
											1155.32(a)(1) 
				  (relating to payment conditions for individual services).
(2) A face-to-face assessment has been
				  completed by a graduate-level professional within 15 days of the initiation of
				  group services and prior to completing the ITP in accordance with §
											5240.95 (relating to assessment)
				  or a face-to-face assessment has been reviewed and updated within 12 months of
				  the previous face-to-face assessment.
(3) The assessment and all updates have been
				  signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and
				  written order for group services has been completed within 30 days after the
				  initiation of services in accordance with §
											5240.96 (relating to individual
				  treatment plan) or an ITP has been reviewed and updated within 6 months of the
				  previous ITP.
(5) The ITP and all
				  updates have been reviewed and signed by the youth, young adult, or parent or
				  legal guardian of the child or youth, the staff person who completed the ITP
				  and an individual who meets the qualifications of a clinical director in §
											5240.12 (relating to staff
				  qualifications).
(6) For continued
				  group services, a child, youth or young adult shall have an order written
				  within 12 months of the initiation of the continued services that complies with
				  § 1155.32(a)(1)(ii)-(iv).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PAYMENT FOR INTENSIVE BEHAVIORAL HEALTH SERVICES › Section 1155.35 - Payment conditions for EBT delivered through individual services, ABA services or group services

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment will be made to a licensed IBHS agency for EBT delivered through
				  individual services, ABA services or group services if the following conditions
				  are met:
(1) There is a written order for EBT
				  that meets the requirements of §§
											1155.32(a)(1),
				  1155.33(a)(1) or
				  1155.34(a)(1)
				  (relating to payment conditions for individual services; payment conditions for
				  ABA services; and payment conditions for group services).
(2) A face-to-face assessment has been
				  completed by an individual with the qualifications required by the EBT within
				  15 days of the initiation of the services and prior to completing the ITP in
				  accordance with §
											5240.102 (relating to assessment
				  and individual treatment plan) or a face-to-face assessment has been reviewed
				  and updated within 12 months of the previous face-to-face assessment.
(3) The assessment and all updates have been
				  signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and the
				  written order for services has been completed within 30 days of the initiation
				  of services in accordance with §
											5240.102 or an ITP has been
				  reviewed and updated within 6 months of the previous ITP.
(5) The ITP and all updates have been
				  reviewed and signed by the youth, young adult, or parent or legal guardian of
				  the child or youth, the staff person who completed the ITP and an individual
				  who meets the qualifications of a clinical director in §
											5240.12 (relating to staff
				  qualifications).
(6) For continued
				  EBT, a child, youth or young adult shall have an order written within 12 months
				  of the initiation of the continued services that complies with §§
				  1155.32(a)(1)(ii)-(iv), 1155.33(a)(1)(ii)-(iv) or
				  1155.34(a)(1)(ii)-(iv).
(7) The
				  IBHS agency or the individual providing the EBT has certification or licensure
				  from the National certification organization or entity that developed or owns
				  the EBT.
(8) Services are delivered
				  in accordance with the specific EBT.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PAYMENT FOR INTENSIVE BEHAVIORAL HEALTH SERVICES › Section 1155.36 - Covered services

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will pay for the following IBHS when the
					 services are medically necessary:
(1)
				  Individual services, which include:
(i)
				  Behavior consultation services.
(ii) Mobile therapy services.
(iii) Behavioral health technician
				  services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › PAYMENT FOR INTENSIVE BEHAVIORAL HEALTH SERVICES › Section 1155.37 - Limitations

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is subject to the following limitations:
(1) Services provided to a child, youth or
				  young adult must be included in the agency's approved service
				  description.
(2) Services provided
				  to a child, youth or young adult residing in a 24-hour residential facility
				  will not be paid for unless the IBHS is ordered in accordance with §§
										1155.32(a)(1),
				  1155.33(a)(1) or
				  1155.34(a)(1)
				  (relating to payment conditions for individual services; payment conditions for
				  ABA services; and payment conditions for group services), the order explains
				  why services are needed in addition to services provided by the facility and
				  the service does not duplicate services included in the facility's
				  rate.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › UTILIZATION REVIEW › Section 1155.41 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
					 subject to the utilization review procedures in Chapter 1101 (relating to
					 general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1155 - INTENSIVE BEHAVIORAL HEALTH SERVICES › ADMINISTRATIVE SANCTIONS › Section 1155.51 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
If an IBHS agency is determined to have billed for services
					 inconsistent with MA Program regulations, to have provided services outside the
					 scope of customary standards of clinical practice or to have otherwise violated
					 the standards in the provider agreement, the IBHS agency is subject to the
					 sanctions in Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › GENERAL PROVISIONS › Section 1163.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for medically necessary
						covered inpatient services provided to eligible recipients by a general
						hospital enrolled as a provider under the MA Program. Payment for these
						services is subject to this chapter and Chapter 1101 (relating to general
						provisions).
This section cited in 55 Pa. Code § 1101.31
						  (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › SCOPE OF BENEFITS › Section 1163.21 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients not enrolled in a health
						maintenance organization are eligible for medically necessary inpatient
						hospital services, provided by participating general hospitals and covered by
						the MA Program subject to the conditions and limitations established in this
						chapter and Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › SCOPE OF BENEFITS › Section 1163.22 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients not enrolled in a health
						maintenance organization are eligible for medically necessary inpatient
						hospital services, provided by participating general hospitals and covered by
						the MA Program subject to the conditions and limitations established in this
						chapter and Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › SCOPE OF BENEFITS › Section 1163.23 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are not eligible for
						inpatient hospital services unless the recipient is also categorically needy or
						medically needy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › SCOPE OF BENEFITS › Section 1163.24 - Scope of benefits for General Assistance recipients

Current through Register Vol. 54, No. 28, July 13, 2024
General Assistance recipients, age 21 to 65, whose MA
						benefits are funded solely by State funds, are eligible for medically necessary
						basic health care benefits as defined in Chapter 1101 (relating to general
						provisions). See § 1101.31(e) (relating to scope).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › HOSPITAL CLASSES AND EXCLUDED UNITS › Section 1163.31 - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › HOSPITAL CLASSES AND EXCLUDED UNITS › Section 1163.32 - Hospital units excluded from the DRG prospective payment system

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for
					 inpatient hospital services provided to a recipient admitted to a psychiatric
					 unit of a general hospital as specified in this section, a drug and alcohol
					 rehabilitation unit of a general hospital as specified in this section, or a
					 medical rehabilitation unit of a general hospital as specified in this section,
					 is made under Subchapter B (relating to hospitals and hospital units under cost
					 reimbursement principles).
(b) To
					 be excluded from the prospective payment system, the psychiatric unit, the drug
					 and alcohol rehabilitation unit, or the medical rehabilitation unit of a
					 general hospital shall meet the participation requirements set forth in
					 Subchapter B.
(c) Effective April
					 1, 1987, payment for hospital services performed in a short procedure unit is
					 made under Chapter 1126 (relating to ambulatory surgical center services and
					 hospital short procedure unit services).
The provisions of this §
													1163.32 amended under section
						  443.1(1) of the
						  Public Welfare Code (62 P. S. §
														443.1(1)).
This section cited in 55 Pa. Code §
													1163.51 (relating to general
						  payment policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PROVIDER PARTICIPATION › Section 1163.41 - General participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In addition to the participation
					 requirements established in Chapter 1101 (relating to general provisions)
					 general hospitals shall:
(1) Be licensed by
					 the Department of Health.
(2) Have
					 in effect a utilization review plan approved by Medicare or, for a hospital not
					 participating in Medicare, a utilization review plan approved by the Office of
					 MA. For a utilization review plan to be approved by the Office of MA, it shall
					 comply with §
												1163.73 (relating to the hospital
					 utilization review plan).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PROVIDER PARTICIPATION › Section 1163.43 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the ongoing responsibilities established
						in Chapter 1101 (relating to general provisions), and as a condition of
						continued participation in the MA Program, general hospitals shall comply with
						the following:
(1) Maintain transfer
					 agreements with skilled nursing and intermediate care facilities, private
					 psychiatric hospitals and rehabilitation hospitals, for the prompt and
					 appropriate transfer of patients who no longer need acute inpatient hospital
					 care.
(2) For services provided to
					 MA recipients, keep separate patient statistics and fiscal records on the cost
					 of, and charges for, those services provided in:
(i) A distinct part psychiatric
					 unit.
(ii) A distinct part drug and
					 alcohol rehabilitation unit.
(iii)
					 A distinct part medical rehabilitation unit.
(iv) A hospital-based nursing
					 facility.
(v) Other inpatient
					 settings.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Except for services provided in a hospital unit excluded from the DRG
					 prospective payment system, the Department will pay a prospective rate for
					 inpatient hospital services compensable under the MA Program. See §
											1163.2 (relating to definitions)
					 for the definition of "inpatient hospital services." The Department will base
					 the prospective payment on the DRG into which the patient is classified and on
					 the prospective payment rate assigned to a hospital.
(b) In addition to the DRG prospective
					 payment made by the Department for a patient discharged from the hospital, the
					 Department will reimburse a participating hospital for:
(1) Costs for depreciation and interest for
					 buildings and fixtures under §
												1163.53a (relating to prospective
					 capital reimbursement system).
(2)
					 Costs for direct medical education under §
												1163.55 (relating to payments for
					 direct medical education for Fiscal Years 1993-94 and 1994-95).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.52 - Prospective payment methodology

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will base payment for
					 inpatient hospital services on the classification of inpatient hospital
					 discharges by DRGs used by the Medicare Program.
(b) The Department will assign a DRG to each
					 MA discharge. The assignment of a DRG is based on:
(1) The recipient's diagnoses.
(2) The procedures performed during the
					 recipient's hospital stay.
(3) The
					 recipient's sex.
(4) The
					 recipient's age.
(5) The
					 recipient's discharge status.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.52a - Assignment of DRG-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
Department policy restricts assignment of a neonate DRG
						to those cases in which the recipient is under 1 year of age as of the date of
						admission.
This section amended under section 6(b) of the
						  Regulatory Review Act (71 P. S. §
														745.6(b)) which provides for
						  emergency regulations to take effect for 120 days. Disapproved by the
						  Independent Regulatory Review Commission on July 2, 1993. See 23 Pa.B. 3632
						  (July 31, 1993).
The provisions of this §
													1163.52a amended under sections
						  201 and 443.1(1) of the Public Welfare Code (62 P. S. §§
														201 and
						  443.1(1)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.53 - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.53a - Prospective capital reimbursement system

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department defines allowable
					 depreciation and interest costs for buildings and fixtures under Medicare cost
					 reimbursement principles in 42 CFR Part 413 (relating to principles of
					 reasonable cost reimbursement; payment for end-stage renal disease services).
					 Costs for major moveable equipment are not included in allowable depreciation
					 and interest costs for purposes of this section, but are included as part of
					 the prospective payment rate for operating costs.
(b) The Department will pay for allowable
					 depreciation and interest costs for buildings and fixtures-capital costs-as an
					 add-on percentage to each hospital's prospective payment rate.
(c) The add-on percentage is the
					 case-weighted Statewide average percentage of capital costs to operating costs.
					 The Department will determine the add-on percentage by the following method:
(1) For each hospital, determining MA
					 allowable acute care inpatient operating costs by subtracting MA allowable
					 acute care inpatient capital costs and MA allowable acute care inpatient
					 medical education costs from that hospital's total MA allowable acute care
					 inpatient costs.
(2) For each
					 hospital, dividing MA allowable acute care inpatient capital costs by that
					 hospital's MA allowable acute care inpatient operating costs.
(3) For each hospital, multiplying the ratio
					 determined under paragraph (2) by the number of reported MA acute care
					 inpatient cases at that hospital.
(4) Adding the products determined under
					 paragraph (3) for all hospitals.
(5) Dividing the sum obtained under paragraph
					 (4) by the Statewide number of reported MA acute care inpatient
					 cases.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.54 - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.55 - Payments for direct medical education for Fiscal Years 1993-94 and 1994-95

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For Fiscal
					 Years 1993-94 and 1994-95, the Department will reimburse hospitals for
					 inpatient acute care direct medical education costs that are allowable under
					 Medicare cost principles, subject to the limitations in this section.
(b) For Fiscal Years 1993-94 and 1994-95,
					 prior to a settlement based on audited costs, subject to the limitations in
					 this section, the Department will make monthly interim payments for the MA
					 inpatient acute care portion of a hospital's allowable costs for direct medical
					 education. The Department will calculate a hospital's interim payment to
					 approximate, to the extent practicable, that hospital's final audited MA
					 inpatient acute care direct medical education payment.
(c) For Fiscal Years 1993-94 and 1994-95, a
					 hospital's final audited payment for MA inpatient acute care direct medical
					 education costs will be the lesser of the following:
(1) The hospital's final audited MA inpatient
					 acute care direct medical education payment for the prior fiscal year, as
					 increased for inflation to the fiscal year being audited as provided under
					 subsections (d) and (e).
(2) The
					 hospital's actual audited MA inpatient acute care direct medical education
					 costs for the fiscal year being audited.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.56 - Outliers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except for DRGs
					 specified under subsection (f), the Department will pay the hospital an amount
					 in addition to the DRG payment for the hospital stay under subsection (d) if:
(1) The hospital stay qualifies as a day
					 outlier under subsection (b).
(2)
					 The payment conditions in subsection (c) are met.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.57 - Payment policy for readmissions

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Except as specified in subsection (c), if a recipient is readmitted to a
					 hospital within 30 days of discharge, the Department makes no payment in
					 addition to the hospital's original DRG payment. If the combined hospital stay
					 qualifies as an outlier, an outlier payment will be made.
(b) If a patient is readmitted within 30 days
					 of discharge for the treatment of conditions that could or should have been
					 treated during the previous admission, the Department makes no payment in
					 addition to the hospital's original DRG payment.
(c) Except as specified in subsection (b), if
					 a patient is readmitted to the hospital due to complications of the original
					 diagnosis and this results in a different DRG with a higher payment rate, the
					 Department pays the higher DRG payment rate rather than the original DRG
					 rate.
(d) Except as specified in
					 subsection (b), if a patient is readmitted to the hospital due to conditions
					 unrelated to the previous admission, the Department considers the readmission a
					 new admission for payment purposes.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.58 - Payment policy for transfers

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 For purposes of this chapter, a transfer is limited to those instances in which
					 a patient is transferred between two hospitals both of which are paid under the
					 MA prospective payment system.
(b)
					 Except as specified in subsection (g), if an inpatient is transferred, the
					 hospital that discharges the inpatient as defined in §
											1163.51 (relating to general
					 payment policy) is paid the full DRG rate established under this
					 chapter.
(c) Except as specified in
					 subsections (e) and (f), if an inpatient is transferred, the transferring
					 hospital is paid the lesser of one of the following:
(1) A per diem rate for each day of inpatient
					 care determined by dividing the hospital's appropriate DRG payment rate for the
					 case by the Statewide average length of stay for the DRG.
(2) The hospital's appropriate DRG payment
					 rate as determined under this chapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.59a - Utilization guidelines for inpatient hospital drug and alcohol services under the MA Program-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For inpatient adult drug and alcohol
					 services rendered on or after May 1, 1998, the Department will use the
					 Pennsylvania Client Placement Criteria (PCPC) developed by the Bureau of Drug
					 and Alcohol Programs (BDAP) in the Department of Health as utilization
					 guidelines, both for prospective and retrospective reviews of patient
					 care.
(b) If the BDAP modifies the
					 PCPC guidelines, the Department will also adopt those modifications.
(c) Providers who do not already have a copy
					 of the PCPC may obtain one by contacting the Department of Health, Bureau of
					 Drug and Alcohol Programs, Room 929, Health and Welfare Building, Harrisburg,
					 Pennsylvania 17108.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.60 - Payment conditions for sterilizations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for covered sterilization
					 procedures is made only if:
(1) The
					 individual requesting sterilization has voluntarily given informed consent
					 under subsection (b).
(2) The
					 individual is 21 years old or older at the time informed consent is
					 obtained.
(3) The individual is not
					 a mentally incompetent individual or an institutionalized individual. For the
					 purposes of this chapter, a mentally incompetent individual is a person who has
					 been declared mentally incompetent by a Federal, State or local court of
					 competent jurisdiction for any purpose unless he has been declared competent
					 for purposes which include the ability to consent to
					 sterilization.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.61 - Payment conditions for hysterectomies

Current through Register Vol. 54, No. 28, July 13, 2024
Payment is made for a hysterectomy if:
(1) The hysterectomy is performed for a valid
					 medical reason other than sterilization.
(2) Except as stated otherwise in
					 subparagraphs (i) and (ii), the individual and her representative, if any, has
					 been advised orally and in writing, that the hysterectomy will render the
					 individual permanently incapable of reproducing. The individual or her
					 representative, if any, must sign a Patient Acknowledgement Form for
					 Hysterectomy which acknowledges receipt of that information unless one of the
					 following occurs:
(i) The individual is
					 already sterile at the time of the hysterectomy and the physician who performs
					 the hysterectomy certifies in writing that the individual was sterile prior to
					 the procedure and states the cause of the sterility. The reasons may include,
					 but are not limited to congenital disorders, a previous sterilization or
					 postmenopausal sterility.
(ii) The
					 individual requires a hysterectomy because of a life-threatening emergency
					 situation in which the physician determines that prior acknowledgement is not
					 possible. The physician must include a description of the nature of the
					 emergency, documenting that prior acknowledgement was not possible.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.62 - Payment conditions for abortions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Coverage for abortions funded under the
					 MA Program is available only if:
(1) A
					 physician has certified in writing and documented in the patient's record that
					 the life of the woman would be endangered if the pregnancy were allowed to
					 progress to term. The decision as to whether the woman's life is endangered is
					 a medical judgment to be made by the woman's physician. Payment will be made
					 for an inpatient hospitalization for purposes of an abortion only if a
					 "Physician Certification for an Abortion" form signed by a licensed physician
					 is submitted with the invoice for payment. A sample of the required "Physician
					 Certification for an Abortion" form appears in the Provider Handbook.
(2) If the recipient was the victim of rape
					 or incest and the incident was reported to a law enforcement agency or to a
					 public health service within 72 hours of its occurrence in the case of rape and
					 in the case of incest within 72 hours of the time the physician notified the
					 patient that she was pregnant. A law enforcement agency is an agency or part of
					 an agency which is responsible for the enforcement of the criminal laws, such
					 as a local police department or sheriff's office. A public health service is an
					 agency of the Federal, State or local government or a facility certified by the
					 Federal government as a Rural Health Clinic which provides health or medical
					 services. Those agencies whose principal function is the performance of
					 abortions are not considered public health agencies.
(i) Payment is made for inpatient
					 hospitalization only if a "Physician Certification for an Abortion" form,
					 signed by a licensed physician is submitted with the invoice for payment along
					 with documentation signed by an official of the law enforcement agency or
					 public health service to which the rape or incest was reported. The
					 documentation must include:
(A) The
					 information specified in subsection (a)(2)(ii).
(B) A statement that the report was signed by
					 the person making the report.
(ii) The report of the rape or incest need
					 not be made by the victim herself but can be reported by another person. The
					 report need not be made in person but may be made by mail. The report itself
					 shall be signed by the person who reports the rape or incest and must include:
(A) The name and address of the
					 victim.
(B) The name and address of
					 the person who made the report if different from the victim.
(C) The date of the incident if it was
					 rape.
(D) The date the report was
					 made.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.63 - Billing requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 hospital shall submit invoices to the Department in accordance with the
					 instructions in the Provider Handbook.
(b) The hospital may not submit an invoice
					 until the recipient has been one of the following:
(1) Discharged from the hospital as defined
					 in §
												1163.51 (relating to general
					 payment policy).
(2) Transferred to
					 another hospital that is paid under the Pennsylvania MA DRG prospective payment
					 system.
(3) Treated as an inpatient
					 in the hospital continuously for 90 or more days.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.64 - Cost reports

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
					 hospital shall complete form MA 336 (Financial Report For Hospital and
					 Hospital-Health Care Complex Under the Medical Assistance Program of the
					 Department of Human Services, Commonwealth of Pennsylvania) or its successor in
					 accordance with the Medicare principles governing reasonable cost reimbursement
					 in Medicare's Provider Reimbursement Manual (HIM-15) and in accordance with the
					 instructions accompanying the cost report.
(b) The hospital shall submit form MA 336 or
					 its successor to the Department's Office of MA by September 30th of each year.
					 If the hospital participates in Medicare, a completed copy of the Medicare cost
					 report also shall be submitted to the Department as a supplement to form MA 336
					 or its successor.
(c) The
					 hospital's cost report shall:
(1) Be prepared
					 using the accrual basis of accounting.
(2) Except as noted in paragraph (4), cover a
					 fiscal period of 12 consecutive months from July 1 through June 30.
(3) Include all information necessary for the
					 proper determination of costs payable under the program including financial
					 records and statistical data.
(4)
					 In the case of a hospital beginning operations during the fiscal year, cover
					 the period from the date of approval for participation in the MA Program to the
					 end of the fiscal year.