reglab/statecodes huggingface dataset:
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 1163.65 - Payment for out-of-State hospital services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department pays for compensable
					 inpatient hospital services furnished by an out-of-State hospital to an
					 eligible Pennsylvania recipient if one of the following occurs:
(1) Residents in a given area generally
					 receive their care in a particular out-of-State hospital. This would apply when
					 the out-of-State hospital is closer to, or substantially more accessible from,
					 the residence of the recipient than the nearest hospital within this
					 Commonwealth that is adequately equipped and is available for the treatment of
					 the individual's illness.
(2)
					 Documentation is provided verifying one of the following:
(i) While temporarily out-of-State, the
					 recipient required inpatient hospital services on an emergency basis. For the
					 purpose of this chapter, emergency services are those inpatient hospital
					 services that are necessary to prevent the death, or serious impairment of the
					 health of the individual, and which, because of the threat to the life or
					 health of the individual, require the use of the most accessible hospital
					 available that is equipped to furnish the services.
(ii) An out-of-State hospital is the only
					 facility equipped to provide the type of care that the individual
					 requires.
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 1163.66 - Third-party liability

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Hospitals shall utilize the available third-party resources for services a
					 recipient receives while in the hospital. Medicare lifetime reserve days are
					 considered available resources.
(b)
					 If expected payment by a third party resource is not realized, the hospital may
					 bill the MA Program.
(c) If the
					 hospital receives reimbursement from a third-party subsequent to payment from
					 the Department, the hospital shall repay the Department by submitting a claim
					 adjustment.
(d) If a recipient or
					 the legal representative of a recipient requests a copy of the hospital
					 invoice, the hospital shall submit a copy of the invoice and the request to the
					 Bureau of Claim Settlement, MA Recovery Unit, at the address specified in the
					 Provider Handbook. The Bureau of Claim Settlement will forward the requested
					 copy to the requestor and take follow-up action necessary to ensure the
					 repayment of MA expenditures.
(e)
					 For a hospitalization with a discharge date on or after July 1, 2007, if a
					 recipient is entitled to Medicare Part A benefits, the Department will not pay
					 any deductible and coinsurance amounts if the Medicare payment exceeds the
					 applicable DRG payment, including any outlier payments. If the Medicare payment
					 is less than the applicable DRG payment including any outlier payments, the
					 Department pays Medicare deductible and coinsurance amounts to the extent that
					 the Department's payment, the Medicare payment and any other resources
					 available to the recipient for the hospital inpatient care combined do not
					 exceed the applicable DRG payment, including any outlier payments. The
					 Department will not pay more than the maximum deductible and coinsurance
					 amounts.
(f) Except as specified in
					 subsection (g), if a recipient is entitled to hospital insurance benefits other
					 than Medicare Part A, the Department will pay the applicable DRG payment rate
					 minus the insurer's liability amount and other resources available to the
					 recipient for hospital care, including any Medicare Part B payment.
(g) If the resources available to a recipient
					 for inpatient hospital care equal or exceed the Department's applicable DRG
					 payment rate, the Department will make no payment for the hospital
					 care.
(h) The hospital shall
					 utilize resources available through Medicare Part B for those services provided
					 in the hospital that are covered and approved for payment by
					 Medicare.
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 › UTILIZATION CONTROL › Section 1163.70 - Changes of ownership or control

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A hospital is not entitled to additional
					 reimbursement due solely to a change of ownership or control.
(b) If a change of ownership occurs, the
					 Department will establish prospective payment base rates as follows:
(1) If the change involves only one hospital,
					 the Department will use the prospective payment rate assigned to the hospital
					 before the change.
(2) If the
					 change combines two or more hospitals into a single entity, such as a merger or
					 consolidation, the Department will establish a new prospective payment rate for
					 the new entity by averaging rates of the previous entities on a case-weighted
					 basis. To determine that case-weighted average, the Department will use the MA
					 cases of each previously enrolled hospital as reported in the most recent
					 fiscal year for which all the previous entities filed acceptable Cost Reports
					 (MA 336).
(3) If the change divides
					 one enrolled hospital into two or more entities, the Department will use the
					 prospective payment rate assigned to the hospital before the change, for the
					 resulting entities.
(4) The
					 Department will not rebase rates established under this subsection until it
					 rebases rates Statewide.
(5) If the
					 Department rebases rates Statewide after a change in ownership has occurred, by
					 using a base year which predates or corresponds to the year of change, the
					 Department will use the Cost Reports (MA 336) and the claims data for the base
					 year regardless of who owned the entity in that base year.
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 › UTILIZATION CONTROL › Section 1163.71 - Scope of utilization review process

Current through Register Vol. 54, No. 28, July 13, 2024
Hospital inpatient services provided to MA recipients are
						subject to the utilization review procedures set forth in this chapter and 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 › UTILIZATION CONTROL › Section 1163.72 - Utilization review: general

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Each hospital shall conduct reviews of each MA recipient's need for admission
					 for inpatient hospital services and short procedure unit services in accordance
					 with the Department's Manual for Diagnosis Related Group Review of Inpatient
					 Hospital Services.
(b) The
					 Department's Bureau of Utilization Review regularly monitors each hospital's
					 utilization review program to determine whether or not it is operating in
					 accordance with the utilization review process and the MA regulations in this
					 part. Monitoring is carried out through review of the hospital's admissions,
					 readmissions, transfers, outliers, patient records, physicians' practice
					 patterns and paid claims.
(c) The
					 Department approves or disapproves the recipient's need for admission or
					 readmission through its utilization review process.
(d) If a discrepancy exists between a
					 hospital's utilization review plan and the instructions set forth in the
					 Department's Manual for Diagnosis Related Group Review of Inpatient Hospital
					 Services, the Department's manual takes precedence.
(e) If the Department requests additional
					 information on an admission or a day or cost outlier, the hospital shall submit
					 the information within 30 calendar days of the request. If the hospital does
					 not submit the requested information within 30 calendar days, the Department
					 will make a decision based on the available information.
(f) Unless additional information is
					 requested, the Department approves or disapproves the admission of each MA
					 recipient within 5 days of receipt of the Hospital Admission DRG/CHR
					 Certification Form.
(g) If the
					 Department requests additional information for a hospital admission, the
					 Department will notify the hospital of the approval or disapproval within 30
					 days of receipt of the additional information.
This section cited in 55 Pa. Code §
													1126.71 (relating to scope of
						  utilization review process).
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 › UTILIZATION CONTROL › Section 1163.73 - Hospital utilization review plan

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Hospital utilization review plans shall
					 provide for a utilization review committee that meets the requirements set
					 forth in §
											1163.74 (relating to requirements
					 for hospital utilization review committees).
(b) Hospital utilization review plans shall
					 describe the organization, composition and functions of the utilization review
					 committee and specify the frequency of the meetings of the committee.
(c) Hospital utilization review plans shall
					 provide for a review of each recipient's admission to the hospital under §
											1163.77 (relating to admission
					 review requirements).
(d) Hospital
					 utilization review plans shall provide for a review of potential outlier cases
					 under §
											1163.78a or §
											1163.78b (relating to review
					 requirements for day outliers; or review requirements for cost
					 outliers).
(e) Hospital utilization
					 review plans shall describe the methods that the utilization review committees
					 use to select and conduct Medical Care Evaluation studies under §
											1163.79 (relating to Medical Care
					 Evaluation studies).
This section cited in 55 Pa. Code §
													1163.41 (relating to general
						  participation requirements).
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 › UTILIZATION CONTROL › Section 1163.74 - Requirements for hospital utilization review committees

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A hospital shall have a utilization
					 review committee composed of two or more physicians, and assisted by other
					 professional personnel as required under
					 42 CFR
					 456.106 (relating to organization and
					 composition of UR committee; disqualification from UR committee membership).
					 Committee members need not be members of the hospital medical staff.
(b) A member of the hospital utilization
					 review committee may not participate in the review of a patient's case if he is
					 or was responsible for the care of that patient.
(c) A member of the hospital utilization
					 review committee may not have a direct or indirect financial interest in any
					 hospital.
This section cited in 55 Pa. Code §
													1163.73 (relating to 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 › UTILIZATION CONTROL › Section 1163.75 - Responsibilities of the hospital utilization review committee

Current through Register Vol. 54, No. 28, July 13, 2024
The hospital utilization review committee or its
						representative shall:
(1) Conduct
					 admission reviews under §
											1163.77 (relating to admission
					 review requirements).
(2) Conduct
					 continued stay reviews for potential outliers under §
											1163.78a (relating to review
					 requirements for day outliers).
(3)
					 Conduct Medical Care Evaluation studies under §
											1163.79 (relating to Medical Care
					 Evaluation studies).
(4) Conduct
					 reviews for medical necessity of services for potential cost under §
											1163.78b (relating to review
					 requirements for cost outliers).
(5) Provide that each recipient's record
					 include:
(i) An identification of the
					 recipient.
(ii) Copies of the
					 certification of admission document.
(iii) The name of the recipient's
					 physician.
(iv) The date of
					 admission and date of application for and authorization of MA benefits if
					 application is made after admission.
(v) The initial and subsequent review dates
					 specified under this chapter.
(vi)
					 Documentation by the attending physician justifying the recipient's need for
					 admission.
(vii) Documentation by
					 the attending physician justifying the recipient's continued need for inpatient
					 hospital services if requesting consideration as a day or cost
					 outlier.
(viii) Other supporting
					 material the utilization review committee believes appropriate.
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 › UTILIZATION CONTROL › Section 1163.76 - Plan of care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Before
					 admission or no later than 2 days after admission of a recipient to a hospital,
					 the attending or staff physician shall establish, and include in the
					 recipient's medical record, an individual written plan of care.
(b) The plan of care shall include:
(1) Medical justification for admission and
					 continued stay.
(2) Diagnoses,
					 symptoms, complaints and complications indicating the need for
					 admission.
(3) A description of the
					 functional level of the individual.
(4) Orders for medications, treatments,
					 restorative and rehabilitative services, activities, therapies, social services
					 and diet.
(5) Plans for continuing
					 care including review and modification of the plan of care.
(6) Plans for discharge.
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 › UTILIZATION CONTROL › Section 1163.77 - Admission review requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The hospital utilization review committee
					 or its representative shall review the need for admission of each MA recipient
					 admitted to the hospital within 24 hours after admission. Transfers and
					 readmissions are considered new hospital admissions for utilization review
					 purposes.
(b) The hospital
					 utilization review committee shall make a final determination of the need for
					 admission within 2 working days after admission, unless the case has been
					 designated for preadmission review in accordance with the Department's Manual
					 for Diagnosis Related Group Review of Inpatient Hospital Services.
(c) If the recipient is readmitted to the
					 hospital within 7 days of discharge, the admission review shall include a
					 review of the patient's previous admission to determine if:
(1) The readmission is for the provision of
					 services that could or should have been provided during the previous
					 admission.
(2) The readmission is
					 the result of complications of the conditions that led to the previous
					 admission.
(3) The readmission is
					 unrelated to the previous admission.
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 › UTILIZATION CONTROL › Section 1163.78a - Review requirements for day outliers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If a hospital intends to apply for an
					 outlier payment on the basis of the hospital stay's qualifying as a day
					 outlier, the hospital utilization review committee or its representative shall
					 review the need for continued stay of the MA case.
(b) The hospital utilization review committee
					 shall establish written criteria on which it bases a recipient's need for
					 continued stay. The criteria shall be based on the recipient's medical
					 condition and must be more extensive for those cases known to be associated
					 with high costs, associated with the frequent furnishing of excessive services
					 or authorized by a physician whose patterns of care are questionable.
(c) The hospital utilization review committee
					 or its representative shall assess the need for continued stay by comparing the
					 case to the written criteria established under subsection (b).
(d) If a hospital stay qualifies as a day
					 outlier under §
											1163.56 (relating to outliers) the
					 hospital utilization review committee or its representative shall assign
					 subsequent review dates based on the date continued hospitalization will no
					 longer be necessary.
(e) The
					 hospital utilization review committee shall provide that the justification for
					 the recipient's need for hospital inpatient services be documented in the
					 patient's record.
(f) The hospital
					 utilization review committee shall allow the attending physician the
					 opportunity to present his views before making a final decision on the need for
					 continued stay.
(g) In the event of
					 an adverse determination, the hospital utilization review committee shall
					 follow the procedures set forth in §
											1163.80 (relating to adverse
					 determinations).
This section cited in 55 Pa. Code §
													1163.73 (relating to hospital
						  utilization review plan); and 55 Pa. Code §
													1163.75 (relating to
						  responsibilities of the hospital utilization review
						  committee).
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 › UTILIZATION CONTROL › Section 1163.78b - Review requirements for cost outliers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If a hospital intends to apply for an
					 outlier payment on the basis of the hospital stay's qualifying as a cost
					 outlier, the hospital utilization review committee or its representative shall
					 review the services provided to the recipient to determine medical
					 necessity.
(b) The utilization
					 review committee or its representative shall identify services provided to the
					 recipient listed as noncompensable services and items and services provided
					 during noncompensable outlier days as specified under §
											1163.59 (relating to
					 noncompensable services, items and outlier days).
This section cited in 55 Pa. Code §
													1163.73 (relating to hospital
						  utilization review plan); and 55 Pa. Code §
													1163.75 (relating to
						  responsibilities of the hospital utilization review
						  committee).
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 › UTILIZATION CONTROL › Section 1163.79 - Medical Care Evaluation studies

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The hospital utilization review committee
					 shall conduct Medical Care Evaluation (MCE) studies under this
					 section.
(b) MCE studies shall
					 identify and analyze medical or administrative factors related to patient care
					 rendered in the hospital and, when indicated, make recommendations for changes
					 that would be beneficial to patients, staff, the hospital and the
					 community.
(c) MCE studies shall
					 include analysis of at least:
(1)
					 Admissions.
(2) Length of
					 stay.
(3) Diagnostic
					 categories.
(4) Ancillary services,
					 including drugs and biologicals.
(5) Professional services performed in the
					 hospital.
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 › UTILIZATION CONTROL › Section 1163.80 - Adverse determinations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If
					 the hospital utilization review committee denies admission or continued stay,
					 the committee shall forward a letter regarding the adverse determination to:
(1) The recipient.
(2) The recipient's next of kin or sponsor,
					 if applicable.
(3) The attending
					 physician.
(4) The hospital
					 administrator.
(5) The Office of
					 MA, Bureau of Utilization Review.
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 › ADMINISTRATIVE SANCTIONS › Section 1163.91 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
If the Department determines that a provider billed for
						services inconsistent with this part, provided incorrect information on the
						billing invoice regarding a patient's diagnosis or procedures performed during
						the period of hospitalization or otherwise violated the standards set forth in
						the provider agreement, the provider is subject to the sanctions described 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 › ADMINISTRATIVE SANCTIONS › Section 1163.92 - Administrative sanctions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the
					 hospital utilization review committee fails to review a MA recipient's need for
					 admission or fails to request approval for the admission through the
					 Department's Bureau of Utilization Review, the Department denies payment for
					 the hospital stay.
(b) For
					 potential day outlier cases, if the Department determines that a day of care
					 occurring any time during the period of hospitalization was not medically
					 necessary, the Department excludes those days in determining entitlement to any
					 outlier payment amount.
2(c) For
					 potential cost outlier cases, if the Department determines that services or
					 items provided by the hospital were not medically justified, or were
					 unnecessary, inappropriate or otherwise noncompensable, the Department excludes
					 the cost for those services as well as the cost of services and items related
					 to the provision of that service in determining entitlement to and payment
					 amount for an outlier payment.
(d)
					 If the Department determines that a hospital bill for services inconsistent
					 with this part, provided incorrect information on the billing invoice regarding
					 a patient's diagnosis or procedures performed during the period of
					 hospitalization, the Department denies payment for the claims either
					 concurrently or retroactively.
(e)
					 If the Department determines that a hospital claim has been inappropriately
					 coded based on information in the patient's medical record or discovers coding
					 errors, the Department corrects the claim for payment purposes.
(f) If the Department determines that a
					 hospital's utilization review process is not in accordance with the
					 Department's Manual for Diagnosis Related Group Review of Inpatient Hospital
					 Services, the hospital shall take corrective action within the time specified
					 by the Department.
(g) If the
					 Department has requested that a hospital take corrective action on its
					 utilization review process and the hospital fails to do so within the specified
					 time, the Department will terminate the hospital's provider
					 agreement.
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 › RIGHT OF APPEAL › Section 1163.101 - Provider right to appeal

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 The hospital's right to appeal is under Chapter 1101 (relating to general
					 provisions).
(b) Hospitals and
					 practitioners do not have the right to a separate appeal on the same
					 case.
(c) For cases undergoing the
					 appeal process, payment, including adjustments, will be withheld until the case
					 is adjudicated.
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 › TECHNICAL COMPUTATIONS › Section 1163.122 - Determination of DRG relative values

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The relative values for the forthcoming
					 fiscal year are based on the following:
(1)
					 The Department's most recent paid claims data available for at least a 2-year
					 period. For example, the relative values to be used for Fiscal Year 1985-86 are
					 based on paid claims data from the period July 1, 1982-December 21, 1984. The
					 Department establishes a data base of claims appropriate for payment under the
					 DRG payment system by removing claims:
(i)
					 For distinct part psychiatric units excluded from the DRG payment
					 system.
(ii) For distinct part drug
					 and alcohol treatment units excluded from the DRG payment system.
(iii) For services previously paid as
					 inpatient hospital services but which are no longer paid as inpatient
					 claims.
(iv) For those that group
					 into DRGs 469 and 470.
(v) For
					 those indicating that Medicare made part of the payment.
(vi) For those involving patient transfers,
					 except for transfers occurring in DRGs 385 and 456.
(vii) For distinct part medical
					 rehabilitation units excluded from the DRG payment system.
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 › TECHNICAL COMPUTATIONS › Section 1163.126 - Computation of hospital specific base payment rates

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A hospital's base payment rate, which is
					 exclusive of capital, will be the amount determined under this
					 section.
(b) The Department will
					 determine a hospital's case mix adjusted cost per case by first identifying the
					 hospital's reported MA allowable costs from the hospital's base year Fiscal
					 Year 1986-87 Cost Report (MA 336) and from this amount subtracting each of the
					 following items:
(1) The MA portion of the
					 hospital's inpatient costs for direct medical education.
(2) The MA portion of the hospital's
					 allowable net inpatient costs for depreciation and interest for buildings and
					 fixtures.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › GENERAL PROVISIONS › Section 1163.401 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This subchapter
					 applies to freestanding medical rehabilitation hospitals, drug and alcohol
					 rehabilitation hospitals and drug and alcohol rehabilitation and medical
					 rehabilitation units of general hospitals.
(b) The MA Program provides payment for
					 medically necessary covered inpatient services provided to eligible recipients
					 by providers of inpatient hospital care enrolled in the MA Program. Payment for
					 these services is subject to this chapter and Chapter 1101 (relating to general
					 provisions).
The provisions of this §
													1163.401 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › SCOPE OF BENEFITS › Section 1163.421 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients are eligible for medically
						necessary inpatient hospital services, provided by participating general or
						rehabilitation 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › SCOPE OF BENEFITS › Section 1163.422 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients are eligible for medically
						necessary inpatient hospital services, provided by participating general or
						rehabilitation hospitals and covered by the MA Program subject to the
						conditions and limitations established by 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › SCOPE OF BENEFITS › Section 1163.423 - 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › SCOPE OF BENEFITS › Section 1163.424 - 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PROVIDER PARTICIPATION › Section 1163.441 - 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), a
					 cost reimbursed provider shall:
(1) Be
					 licensed by the Department of Health.
(2) Have in effect a utilization review plan
					 approved by Medicare or, for providers not participating in Medicare, a
					 utilization review plan approved by the Office of Medical Assistance Programs.
					 For a utilization review plan to be approved by the Office of Medical
					 Assistance Programs, it shall meet the requirements in §
												1163.473 (relating to hospital
					 utilization review plan).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PROVIDER PARTICIPATION › Section 1163.442 - Requirements for reimbursement under this subchapter

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Only the following types of providers are
					 eligible to be reimbursed under this subchapter:
(1) Medical rehabilitation hospitals that
					 fully comply with the Medicare regulations at
					 42 CFR
					 412.23(b) (relating to
					 excluded hospitals: classifications).
(2) Distinct part drug and alcohol
					 rehabilitation units of general hospitals that meet the requirements set forth
					 in subsection (b).
(3) Drug and
					 alcohol rehabilitation hospitals that meet the requirements set forth in
					 subsection (d).
(4) Medical
					 rehabilitation units of general hospitals that meet the requirements in
					 subsection (e).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PROVIDER PARTICIPATION › Section 1163.443 - 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, rehabilitation hospitals and those
						general hospitals providing distinct part unit services that are reimbursed
						under this subchapter 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. Rehabilitation hospitals need
					 not maintain agreements with each other.
(2) Retain complete, accurate and auditable
					 medical and fiscal records for 4 years for all MA patients under Chapter
					 1101.
(3) Furnish to the Department
					 or its agents, Federal and State auditors, auditable copies of patient records
					 and fiscal records upon request under Chapter 1101.
(4) For those hospitals not participating in
					 Medicare, submit to the Office of MA for review and approval, details of any
					 changes to the hospital's utilization review system, including revisions to the
					 utilization review plan, within 30 days of the date of the change.
(5) Hospitals being reimbursed for distinct
					 part unit services shall keep separate patient statistics and fiscal records on
					 the cost of, and charges for, services provided to MA patients in each distinct
					 part unit being reimbursed under this subchapter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES › Section 1163.451a - Clarification of the term "in writing"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term "in writing" in §
											1163.451(h)
					 (relating to general payment policy) includes orders that are handwritten or
					 transmitted by electronic means.
(b) Written orders transmitted by electronic
					 means must be electronically encrypted or transmitted by other technological
					 means designed to protect and prevent access, alteration, manipulation or use
					 by any unauthorized person.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES › Section 1163.454 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Payment for blood will be limited to the first three pints of whole blood
					 provided during a period of hospitalization. An exception to this limit is made
					 only if the patient has hemophilia, in which case payment is made for the
					 amount of whole blood or blood products the patient requires.
(b) Payment for cost reimbursed drug and
					 alcohol detoxification-rehabilitation services in a general hospital will be
					 limited to days certified under §
											1163.471 (relating to scope of
					 claims review process) during which the inidividual with a drug or alcohol
					 diagnosis is a patient in a drug and alcohol detoxification rehabilitation unit
					 approved by the Department of Health.
(c) A recipient is limited to two periods of
					 therapeutic leave per calendar month. Neither of these periods of therapeutic
					 leave may exceed 12 hours in a calendar day.
The provisions of this §
													1163.454 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 §
													1163.451 (relating to general
						  payment policy); 55 Pa. Code §
													1163.455 (relating to
						  noncompensable services and items); and 55 Pa. Code §
													1163.457 (relating to payment
						  policies relating to out-of-State
						  hospitals).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES › Section 1163.455a - 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES › Section 1163.456 - Third-party liability

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the conditions set forth in Chapter 1101
						(relating to general provisions) the following policies apply to third-party
						resources for hospital services:
(1)
					 Sources of payment other than MA shall be researched prior to billing the
					 Department. If a resource is found, it shall be depleted to the full extent of
					 the liability of that resource prior to billing MA. Lifetime reserve days under
					 Medicare are considered an available resource.
(2) If the hospital receives payment from a
					 third party subsequent to payment from the Department, repayment to the MA
					 Program shall be made by way of a claim adjustment.
This section cited in 55 Pa. Code §
													1163.451 (relating to general
						  payment policy); and 55 Pa. Code §
													1163.457 (relating to payment
						  policies relating to out-of-State
						  hospitals).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES › Section 1163.457 - Payment policies relating to out-of-State hospitals

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment is made on a per diem basis for
					 out-of-State hospital services if the services are covered by the MA Program
					 and are provided under §§
											1163.451-1163.456 and
					 1163.458, including the
					 limitations on inpatient days of care as set forth at §
											1163.454 (relating to limitations
					 on payment). Out-of-State hospitals shall meet the requirements for
					 rehabilitation hospitals and distinct part units as set forth in §
											1163.442 (relating to requirements
					 for reimbursement under this subchapter).
(b) MA recipients are eligible for care
					 provided by an out-of-State hospital only if one of the following occurs:
(1) Residents in a given area generally
					 receive their care in that particular hospital. This would apply when the
					 out-of-State hospital is closer to, or substantially more accessible from, the
					 residence of the recipient than the nearest hospital in this Commonwealth that
					 is adequately equipped to deal with, and is available for the treatment of, the
					 individual's illness or injury.
(2)
					 Documentation is provided verifying one of the following:
(i) While temporarily out of this
					 Commonwealth, the recipient required inpatient hospital services on an
					 emergency basis. For the purposes of this chapter, emergency services are those
					 inpatient hospital services that are necessary to prevent the death, or serious
					 impairment of the health of the individual, and which, because of the threat to
					 the life or health of the individual, necessitate the use of the most
					 accessible hospital available that is equipped to furnish the
					 services.
(ii) An out-of-State
					 hospital is the only facility equipped to provide the type of care that the
					 individual requires.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES › Section 1163.458 - Payment policies relating to same-calendar-day admissions and discharges

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 Department pays for inpatient stays consisting of an admission with subsequent
					 discharge during the same calendar day.
(b) The services must be provided under this
					 chapter.
(c) The interim payment
					 rate is based on 50% of the inpatient per diem rate on file determined in this
					 chapter.
(d) Payment for ancillary
					 services provided to patients during same- calendar-day stays are included in
					 the interim payment. The hospital may not submit a separate bill for these
					 services.
(e) For auditing purposes
					 each same-calendar-day admission and discharge will be counted as 1/2
					 day.
(f) Without exception
					 same-calendar-day stays, regardless of the reason for the stay, are subject to
					 §§
											1163.471-1163.481 (relating to utilization
					 control) and will be reimbursed only if provided under this section.
This section cited in 55 Pa. Code §
													1163.451 (relating to general
						  payment policy); and 55 Pa. Code §
													1163.457 (relating to payment
						  policies relating to out-of-State
						  hospitals).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES › Section 1163.459 - Disproportionate share payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 The Department will annually determine the acute care general hospitals
					 including their distinct part units, private psychiatric hospitals and
					 freestanding rehabilitation hospitals that qualify for disproportionate share
					 payments by the method in subsections (b)-(e). The Department will annually
					 determine the amount of disproportionate share payments for eligible
					 freestanding rehabilitation hospitals and distinct part rehabilitation units of
					 acute care general hospitals by the method in subsections (f)- (i).
(b) A hospital that meets at least one of the
					 requirements under subsection (d) qualifies for disproportionate share payments
					 if one of the following applies:
(1) The
					 hospital's ratio of Title XIX inpatient days to total inpatient days is equal
					 to or greater than one standard deviation above the mean of the ratios for
					 hospitals in this Commonwealth. To determine the ratio for an acute care
					 general hospital, the Department will include inpatient days covered under
					 Subchapter A and Chapter 1151 (relating to acute care general hospitals under
					 the prospective payment system; and inpatient psychiatric services), as well as
					 days covered under this subchapter. The Department will include in the database
					 MA administrative days, days of care provided to recipients in other states'
					 Medicaid Programs, MA Health Maintenance Organization (HMO) days and MA Health
					 Insuring Organization (HIO) days.
(2) The hospital's low income utilization
					 rate, as defined under section 1923 of the Social Security Act (42 U.S.C.A. §
													1396r-4(b)(3)), exceeds
					 25% under one of the following methods:
(i)
					 The hospital's low income utilization rate as reported on its Cost Report (MA
					 336) computation of low income utilization rate worksheet exceeds
					 25%.
(ii) The hospital's low income
					 utilization rate as determined by its ratio of Title XIX and General Assistance
					 inpatient days to total inpatient days exceeds 25%. To determine the ratio for
					 an acute care general hospital, the Department will include inpatient days
					 covered under Subchapter A and Chapter 1151, as well as days covered under this
					 subchapter. The Department will include in the database MA administrative days,
					 days of care provided to recipients in other states' Medicaid Programs, MA HMO
					 days and MA HIO days.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › UTILIZATION CONTROL › Section 1163.471 - Scope of claim review process

Current through Register Vol. 54, No. 28, July 13, 2024
All cost reimbursed services provided to MA recipients
						are subject to the utilization review procedures set forth in this chapter and
						in Chapter 1101 (relating to general provisions).
This section cited in 55 Pa. Code §
													1163.454 (relating to limitations
						  on payment); 55 Pa. Code §
													1163.457 (relating to payment
						  policies relating to out-of-State hospitals); and 55 Pa. Code §
													1163.458 (relating to payment
						  policies relating to same-calendar-day admissions and
						  discharges).