reglab/statecodes huggingface dataset:
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 1163.472 - Concurrent hospital review

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 For cost reimbursed services, the Department reviews the need for a recipient's
					 admission and continued hospitalization through its Concurrent Hospital Review
					 (CHR) process and approves or disapproves the stay unless a hospital has been
					 granted an exemption by the Department.
(b) For cost reimbursed services, each
					 hospital shall follow the instructions in the Department's Manual for
					 Concurrent Review of Inpatient Hospital Services. The provisions of the
					 Department's Manual shall take precedence over the hospital's Utilization
					 Review Plan.
This section cited in 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).
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 1163.473 - Hospital utilization review plan

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A hospital participating in the MA
					 Program shall have in effect a written utilization review plan approved by
					 Medicare that provides for the review of each recipient's need for hospital
					 inpatient services. The terms and conditions imposed under the hospital's
					 utilization review plan for Medicare will, if applicable, apply to MA. If the
					 Medicare utilization review plan is not consistent with this chapter, the
					 Manual for Concurrent Review of Inpatient Hospital Services will take
					 precedence. Those hospitals not participating in Medicare shall submit to the
					 Department's Bureau of Utilization Review, a utilization review plan which
					 meets the requirements of this chapter.
(b) A hospital utilization review plan shall
					 provide for a utilization review committee that meets the requirements set
					 forth in §
											1163.474 (relating to requirements
					 for hospital utilization review committees).
(c) A hospital utilization review plan shall
					 describe the organization, composition and functions of the utilization review
					 committee and shall specify the frequency of the meetings of the
					 committee.
(d) A hospital
					 utilization review plan shall provide that for utilization review purposes each
					 recipient's record includes:
(1)
					 Identification of the recipient.
(2) Copies of the certification of days
					 records.
(3) The name of the
					 recipient's physician.
(4) The date
					 of admission and date of application for an authorization of MA benefits if
					 application is made after admission.
(5) The plan of care required under §
												1163.476 (relating to plan of
					 care).
(6) Initial and subsequent
					 review dates specified under this chapter.
(7) Reasons and plan for continued stay, if
					 the physician believes continued stay is necessary.
(8) 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › UTILIZATION CONTROL › Section 1163.474 - Requirements for hospital utilization review committees

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each 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 §
													1163.457 (relating to payment
						  policies relating to out-of-State hospitals); 55 Pa. Code §
													1163.458 (relating to payment
						  policies relating to same-calendar-day admissions and discharges); and 55 Pa.
						  Code §
													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 › UTILIZATION CONTROL › Section 1163.475 - 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 §
											1163.477 (relating to admission
					 review requirements).
(2) Conduct
					 continued stay reviews under §
											1163.478 (relating to continued
					 stay review requirements).
(3)
					 Conduct Medical Care Evaluation studies under §
											1163.479 (relating to Medical Care
					 Evaluation studies).
(4) Notify the
					 Department's Concurrent Hospital Review Section of a recipient's assigned
					 initial or continued length of stay. This notification shall be done on the
					 form specified and in accordance with the instructions in the Manual for
					 Concurrent Hospital Review of Inpatient Services.
(5) Provide that the justification for a
					 recipient's need for admission and need for continued hospital inpatient
					 services be documented by the attending physician in the recipient's medical
					 record.
(6) Notify the Department's
					 Concurrent Hospital Review Section of a change in a recipient's
					 diagnosis.
(7) Maintain utilization
					 review records for a minimum of 4 years from the date of submission of the year
					 end cost report.
(8) Submit copies
					 of utilization review records and documents, medical records, certification of
					 days records and discharge planning information to the Department upon
					 request.
(9) Maintain copies of
					 certification of days records with the patient's medical record and with the
					 hospital copy of the invoice submitted for payment.
(10) Review cases that the Department has
					 identified as being of questionable utilization of hospital facilities or
					 services or that contain noncompensable services or items as listed in §
											1163.455 (relating to
					 noncompensable services and items).
(11) Initiate discharge planning during the
					 admission review process to provide timely placement in an appropriate level of
					 care for those patients that may require posthospital care.
(12) Follow the procedures specified in the
					 Department's Manual for Concurrent Hospital Review of Inpatient Services in
					 conducting utilization review activities.
This section cited in 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).
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 1163.476 - 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 cost
					 reimbursed hospital or hospital unit, 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
					 must 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › UTILIZATION CONTROL › Section 1163.478 - Continued stay 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 continued stay of each MA
					 recipient admitted to the hospital.
(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 more extensive for those admissions 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 shall assess the need for continued stay in the
					 hospital by comparing each case to the written criteria established under
					 subsection (b).
(d) The hospital
					 utilization review committee shall assign a subsequent review date based on the
					 recipient's medical condition and the time continued hospitalization will no
					 longer be necessary.
(e) The
					 hospital utilization review committee shall conduct the continued stay review
					 and provide the Department's Concurrent Hospital Review Section with the
					 medical justification for the continued stay on or before the expiration date
					 of the initial length of stay. Subsequent reviews shall be completed, and the
					 Department shall be notified before the expiration of the previously assigned
					 length of stay.
(f) If the hospital
					 utilization review committee fails to conduct the continued stay review or
					 fails to notify the Department on or before the expiration of the previously
					 assigned length of stay, the Department does not certify those hospital days
					 between the expiration of the previously assigned length of stay and the date
					 the request for continued stay is made and approved.
(g) If an individual applies for MA while in
					 the hospital, the committee shall:
(1) Assign
					 the continued stay review date within 1 working day after the hospital is
					 notified that the individual has applied for MA.
(2) Contact the Department's Concurrent
					 Hospital Review (CHR) Section for approval of the assigned length of
					 stay.
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 1163.479 - 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 in accordance with 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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › UTILIZATION CONTROL › Section 1163.480 - 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
					 Programs.
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 1163.481 - Utilization review sanctions

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 The Office of MA Programs regularly monitors each hospitals utilization review
					 program to determine whether or not it is operating under the Concurrent
					 Hospital Review process and this part. Monitoring is carried out through review
					 of admissions, continued stays, patient records and claims paid by the
					 Department.
(b) If the Department
					 identifies delays in assigning the initial or continued length of stay, the
					 Department will deny payment for all or part of the hospital stay.
(c) If the Department determines that
					 services or items provided by the hospital were not medically justified, or
					 were unnecessary, inappropriate or noncompensable, the Department will deny
					 payment for the service or item and for services related to the provision of
					 that service or item. Payment will also be denied to the practitioner who
					 ordered the service.
The provisions of this §
													1163.481 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 §
													1163.457 (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).
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 › ADMINISTRATIVE SANCTIONS › Section 1163.491 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Providers determined to have billed for services
						inconsistent with this part, 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 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › ADMINISTRATIVE SANCTIONS › Section 1163.492 - Payment policy relating to administrative sanctions

Current through Register Vol. 54, No. 28, July 13, 2024
If a hospital appeals a decision by the Department to
						fully or partially deny payment for a case, the denied payments will continue
						to be withheld pending decision on the appeal.
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 › RIGHT OF APPEAL › Section 1163.501 - Provider right to appeal

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 The hospital's right of 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 inpatient
					 case. For purposes of this chapter, inpatient services are considered to be
					 those services provided by hospital personnel. Practitioner appeals relating to
					 inpatient services are expected to be resolved through the utilization review
					 process.
(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 B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › CHANGE OF OWNERSHIP › Section 1163.511 - Change of ownership or control

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A hospital or hospital unit is not
					 entitled to additional reimbursement due solely to change of ownership or
					 control.
(b) In the event of change
					 of ownership, the Department will establish interim per diem rates as follows:
(1) If the change involves only one hospital
					 or unit, the Department will use the interim per diem rate assigned to the
					 entity before the change.
(2) If
					 the change combines two or more hospitals or units into a single entity, such
					 as a merger or consolidation, the Department will establish an interim per diem
					 rate for the new entity by averaging the rates of the previous entities on a
					 days-weighted basis. To determine that days-weighted average, the Department
					 will use the MA days of each previously enrolled entity as reported in the most
					 recent fiscal year for which the previous entities filed acceptable Cost
					 Reports (MA 336).
(3) If the change
					 divides one enrolled hospital or unit into two or more entities, the Department
					 will use the interim per diem rate assigned to the entity before the change,
					 for the resulting entities.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › GENERAL PROVISIONS › Section 1181.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This subchapter
					 applies to psychiatric transitional facilities that are enrolled in the MA
					 Program. To the extent that this subchapter is inconsistent with Subchapter B
					 (relating to manual for allowance cost reimbursement for skilled nursing and
					 intermediate care facilities), Subchapter B prevails for psychiatric
					 transitional facilities.
(b) The MA
					 Program provides payment for psychiatric transitional facility services
					 provided to eligible recipients by enrolled providers. Payment for services is
					 made subject to this subchapter, Subchapter B for psychiatric transitional
					 facilities, and Chapter 1101 (relating to general provisions). The upper limit
					 of payment of the MA Program is specified in §
											1181.68 (relating to upper limits
					 of payment).
(c) Any section of
					 this subchapter may not be applied or interpreted out of context.
(d) Extensions of time will be as follows:
(1) The time limits established by this
					 chapter for the filing of an application, cost report, waiver request or appeal
					 cannot be extended except as provided in this section.
(2) Extensions of time in addition to the
					 time otherwise prescribed for providers by this chapter with respect to the
					 filing of an application, cost report, waiver request or appeal may be
					 permitted only if required because of a breakdown in Department procedures
					 justifying relief nunc pro tunc or because of an intervening natural disaster
					 making timely compliance impossible or unsafe.
(3) This subsection supersedes 1 Pa. Code
					 §
												31.15 (relating to extensions of
					 time).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › SCOPE OF BENEFITS › Section 1181.21 - 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 skilled nursing care, intermediate care, and intermediate care for
						the mentally retarded, 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 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › SCOPE OF BENEFITS › Section 1181.22 - 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 skilled nursing care, intermediate care and intermediate care for the
						mentally retarded, 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 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › SCOPE OF BENEFITS › Section 1181.23 - 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
						nursing facility care under the MA Program. Blind and visually impaired
						individuals are, however, eligible for nursing facility services if they
						qualify as categorically or medically needy recipients.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › SCOPE OF BENEFITS › Section 1181.24 - Scope of benefits for qualified Medicare beneficiaries

Current through Register Vol. 54, No. 28, July 13, 2024
Qualified Medicare beneficiaries only are not eligible
						for nursing facility care under the MA Program. Qualified Medicare
						beneficiaries are eligible for nursing facility services if they qualify as
						categorically or medically needy recipients.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › SCOPE OF BENEFITS › Section 1181.25 - 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 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PROVIDER PARTICIPATION › Section 1181.41 - Provider participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements established
						in Chapter 1101 (relating to general provisions), nursing facilities shall meet
						the following requirements:
(1)
					 Skilled nursing care and intermediate care facilities shall be licensed by the
					 Department of Health.
(2)
					 Intermediate care facilities for the mentally retarded shall be licensed by the
					 Department.
(3) Nursing facilities
					 shall abide by applicable Federal, State and local statutes and regulations,
					 including, but not limited to, Title XIX of the Social Security Act
					 (42 U.S.C.A. §§
												1396-1396q), sections
					 443.1-443.6 of the Public Welfare Code
					 (62
					 P. S. §§
												443.1-443.6) and
					 applicable licensing statutes. Nursing facilities shall conform with the
					 requirements specified in Title XIX of the Social Security Act and the
					 regulations promulgated thereunder which are necessary for the Department to
					 receive Federal financial participation for nursing services rendered by the
					 facilities.
(4) A facility with
					 more than 60 licensed beds shall be enrolled and participating in the Medicare
					 Program. This paragraph does not apply to a facility that has no beds certified
					 to provide skilled care.
This section cited in 55 Pa. Code §
													1181.41a (relating to dual
						  participation requirements for Medicare and MA Programs-statement of policy);
						  55 Pa. Code §
													1181.42 (relating to additional
						  participation requirements for hospital-based nursing units); 55 Pa. Code
						  §
													1181.43 (relating to additional
						  participation requirements for intermediate care facilities for the mentally
						  retarded); 55 Pa. Code §
													1181.44 (relating to additional
						  participation requirements for State-operated nursing facilities other than
						  intermediate care facilities for the mentally retarded); 55 Pa. Code §
													1181.504 (relating to background);
						  55 Pa. Code §
													1181.511 (relating to provider
						  conditions of participation); and 55 Pa. Code Chapter 1181 Appendix O (relating
						  to OBRA sanctions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PROVIDER PARTICIPATION › Section 1181.41a - Dual participation requirements for Medicare and MA Programs-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) As a result
					 of the multiple changes to §
											1181.41(4)
					 (relating to provider participation requirements), a facility providing skilled
					 care, enrolled in the MA Program with more than 60 licensed beds, shall also be
					 enrolled in the Medicare program to the extent that it has sufficient beds to
					 accommodate Medicare eligible residents. This does not preclude a facility with
					 a bed complement of under 60 beds from enrolling in the Medicare
					 program.
(b) A facility certified
					 to participate in the Medicare program shall have sufficient beds to
					 accommodate its Medicare eligible residents. Payment will be based on criteria
					 found in §
											1181.51(b)
					 (relating to general payment policy).
(c) If a facility has a total bed complement
					 of more than 60 licensed beds and is not enrolled in the Medicare Program, the
					 Department of Health should be contacted to enroll the skilled beds. Medicare
					 enrollment forms may be requested from and returned to: Department of Health,
					 Division of Long Term Care, Room 526, Health and Welfare Building, Harrisburg,
					 Pennsylvania 17108, (717) 787-1816.
(d) Failure to be enrolled and certified in
					 the Medicare Program will result in denial of claims for a recipient with both
					 Medicare and MA coverage.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PROVIDER PARTICIPATION › Section 1181.42 - Additional participation requirements for hospital-based nursing units

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements listed in
						§§
											1181.41 and
						1181.45 (relating to provider
						participation requirements; and ongoing responsibilities of providers),
						hospital-based nursing units shall meet the following requirements:
(1) The nursing unit shall be composed of
					 former acute care hospital beds that have been converted to and certified for
					 skilled nursing or intermediate care.
(2) The need for the beds shall have been
					 approved by the local health planning agency.
(3) The distinct part unit may not exceed 50%
					 of the facility's total licensed or approved bed complement for acute hospital
					 care. A facility will, however, be granted an exception to the 50% bed limit if
					 it submits written documentation to the Office of MA, Bureau of Long Term Care
					 Programs, substantiating that all of the following criteria have been met:
(i) Beds operated in excess of the 50% limit
					 have been approved by the Department of Health, Division of Need
					 Review.
(ii) The unit is located in
					 an area underserved or lacking long term care beds under an approved local
					 health plan.
(iii) More than 50% of
					 the unit's licensed long term care beds are occupied by MA patients.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PROVIDER PARTICIPATION › Section 1181.43 - Additional participation requirements for intermediate care facilities for the mentally retarded

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
					 addition to §§
											1181.41 and
					 1181.45 (relating to provider
					 participation requirements; and ongoing responsibilities of providers),
					 intermediate care facilities for the mentally retarded shall enter into a
					 written provider agreement with the Office of MA.
(b) State-operated intermediate care
					 facilities for the mentally retarded shall submit budgets on Department forms
					 to the Office of Mental Retardation.
(c) Non-State operated intermediate care
					 facilities for the mentally retarded shall submit cost reports, or budgets if a
					 waiver is granted in accordance with Subchapter C (Reserved), to the Office of
					 Mental Retardation.
(d) The Office
					 of Mental Retardation is responsible for approving projected operating costs
					 and budgets for intermediate care facilities for the mentally
					 retarded.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PROVIDER PARTICIPATION › Section 1181.44 - Additional participation requirements for State-operated nursing facilities other than intermediate care facilities for the mentally retarded

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to the participation requirements in
						§§
											1181.41 and
						1181.45 (relating to provider
						participation requirements; and ongoing responsibilities of providers),
						psychiatric transitional facilities and other State-operated nursing facilities
						other than intermediate care facilities for the mentally retarded shall also
						submit budgets to the Office of Fiscal Management and the Office of MA, Bureau
						of Long Term Care Programs, for review and approval 60 days prior to July 1 of
						each year.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Payment for nursing facility care is subject to the following conditions and
					 limitations:
(1) This chapter and Chapter
					 1101 (relating to general provisions).
(2) The applicable per diem ceilings
					 established under §
												1181.66 (relating to setting
					 ceilings on allowable net operating costs) and announced by the submission of a
					 notice for recommended publication in the
Pennsylvania
					 Bulletin
and suggested codification in the
Pennsylvania
					 Code
as an annex to §
												1181.66 for the location of the
					 facility, level of care, type of facility and date of service involved. Heavy
					 care/intermediate services shall be paid at the higher of a facility's
					 applicable rates for skilled or intermediate care, as limited by the
					 ceilings.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.52 - Payment conditions

Current through Register Vol. 54, No. 28, July 13, 2024
For payment to be made to a nursing facility for covered
						services the applicable conditions of §§
											1181.51-1181.69 (relating to payment for
						nursing facility care) shall be met. Payment shall be subject to the sanctions
						in this chapter and as otherwise provided by law.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.54 - Payment conditions related to the recipient's continued need for care

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Recertification of continued need for care.
(1) A physician, a physician assistant under
					 the supervision of a physician or a nurse practitioner or clinical nurse
					 specialist who is not an employe of the facility but is working in
					 collaboration with a physician shall enter into the recipient's medical record
					 a signed and dated statement that the recipient continues to need skilled,
					 heavy care/intermediate or intermediate level of care, as applicable. For a
					 certification for the skilled level of care to be considered valid, the
					 physician, physician assistant, nurse practitioner or clinical nurse specialist
					 shall certify that the criteria specified in Appendix E (relating to skilled
					 nursing care) have been met. For a certification for the heavy
					 care/intermediate level of care to be considered valid, the physician,
					 physician assistant, nurse practitioner or clinical nurse specialist shall
					 certify that the criteria in Appendix F (relating to heavy care/intermediate
					 services) have been met.
(2)
					 Recertification of the need for care of a recipient receiving care in an ICF/MR
					 shall be made at least once every 365 days after the initial certification as
					 specified in Appendix Q (Reserved).
(3) Recertification of the need for care of a
					 recipient receiving skilled nursing facility services shall be made as follows:
(i) At least 30 days after the date of the
					 initial certification.
(ii) At
					 least 60 days after the date of the initial certification.
(iii) At least 90 days after the date of the
					 initial certification and every 60 days thereafter.
(4) Recertification of the need for care of a
					 recipient receiving heavy care/intermediate or intermediate care services shall
					 be made as follows:
(i) At least 60 days after
					 the date of the initial certification.
(ii) At least 180 days after the date of the
					 initial certification.
(iii) At
					 least 12 months after the date of the initial certification.
(iv) At least 18 months after the date of the
					 initial certification.
(v) At least
					 24 months after the date of the initial certification and every 12 months
					 thereafter.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.55 - General limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
The payment limits specified in this section apply to
						payment to nursing facilities for nursing facility care.
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.56 - Limitations on payment for reserved beds

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will make payment to a nursing facility
						for a reserved bed when the recipient is absent from the facility for a
						continuous 24-hour period because of hospitalization or therapeutic leave. Each
						reserved bed for therapeutic leave shall be recorded on the facility's daily
						census record and invoice. If a bed is being reserved for a recipient who has
						been hospitalized and that bed is being temporarily occupied by another
						recipient, the occupied bed shall be recorded on the facility's daily census
						record and the invoice. A reserved bed shall be available for the recipient
						upon the recipient's return to the facility. The following limits on payment
						for reserved bed days apply:
(1)
Hospitalization
. A recipient receiving skilled nursing care,
					 intermediate care or intermediate care for the mentally retarded-except a
					 recipient in a State-operated intermediate care facility for the mentally
					 retarded-is eligible for a maximum 15 consecutive reserved bed days per
					 hospitalization. The Department will pay a facility at a rate of one-third of
					 the facility's current interim per diem rate on file with the Department for a
					 hospital reserved bed day.
(2)
Therapeutic leave
. Payment for therapeutic leave days is
					 limited as follows:
(i) A recipient receiving
					 skilled nursing care is eligible for a maximum of 15 days per calendar year for
					 therapeutic leave outside the facility if the leave is included in the
					 individual's plan of care and is ordered by the attending physician.
(ii) A recipient receiving intermediate care
					 is eligible for a maximum of 30 days per calendar year of therapeutic leave
					 outside the facility if the leave is included in the individual's plan of care
					 and is ordered by the attending physician.
(iii) A recipient receiving intermediate care
					 for the mentally retarded is eligible for a maximum of 75 days per calendar
					 year for therapeutic leave outside the facility.
(iv) A recipient receiving both skilled and
					 intermediate level of care during the calendar year is eligible for a maximum
					 of 30 days per calendar year for therapeutic leave.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.56a - Limitations on payment for reserved beds-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Interpretation.
The Department interprets §
											1181.56 (relating to limitations
					 on payments for reserved beds) to mean that for each continuous 24-hour period
					 the patient is absent from the facility, the nursing home should bill the
					 Department for a hospital or therapeutic leave day, under the limitations set
					 forth in this chapter. Furthermore, when the cycle-continuous 24-hour period-is
					 broken, the home will bill the Department for a facility day.
(b)
Discussion.
The
					 Department has seen evidence that some nursing homes are not following the
					 interpretation set forth in subsection (a) of how to bill for reserved days.
					 The following examples should serve as guidelines to help nursing homes bill
					 for reserved days properly.
(1)
Example 1.
A nursing home resident leaves the facility May 4,
					 1987 at 2:30 p.m. and returns to the facility May 5, 1987 at 10:30 a.m. May 4,
					 1987 should be billed as a facility day and May 5, 1987 should also be billed
					 as a facility day because the patient was not absent from the facility for a
					 continuous 24-hour period.
(2)
Example 2.
A nursing home resident leaves the facility on May
					 4, 1987 at 11 a.m. and returns to the facility May 5, 1987 at 1 p.m. May 4,
					 1987 should be billed as a reserve bed day and May 5, 1987 should be billed as
					 a facility day. The patient was absent from the facility for a continuous
					 24-hour period from May 4, 1987 at 11 a.m. to May 5, 1987 at 11 a.m.
(3)
Example 3.
A nursing
					 home resident leaves the facility on May 4, 1987 at 9 a.m. and returns to the
					 facility May 11, 1987 at 12 noon. May 4, 1987 through May 10, 1987 should be
					 billed as reserve bed days. May 11, 1987 should be billed as a facility
					 day.
(4)
Example
					 4.
A nursing home resident leaves the facility May 1, 1987 at 10 a.m.
					 and returns to the facility May 16, 1987 at 1 p.m. May 1, 1987 through May 15,
					 1987 should be billed as reserve bed days and May 16, 1987 should be billed as
					 a facility day.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.56b - Charges for bed hold days-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Under the Omnibus Budget Reconciliation
					 Act of 1987, if a nursing facility resident is transferred to a hospital, the
					 resident shall be permitted to return to the nursing facility immediately upon
					 the first availability of a bed in a semiprivate room in the facility if, at
					 the time of readmission, the resident requires the services provided by the
					 facility.
(b) If a nursing facility
					 resident indicates in writing a desire to pay the nursing facility to keep the
					 resident's bed vacant in anticipation of the resident's return to the facility
					 after the 15-day bed hold, the nursing facility may charge the resident to hold
					 the bed the resident occupied prior to transferring to the hospital.
(c) The nursing facility may not charge the
					 resident more than the MA rate paid for the resident's care prior to the
					 resident's transfer to the hospital.
(d) The nursing facility may not charge the
					 resident to hold a bed other than the bed the resident occupied prior to the
					 resident's transfer to the hospital.
(e) Nursing facilities enrolled in the MA
					 Program shall adhere to this chapter.
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.56c - Reimbursement for hospital reserved bed days during a Medicare benefit period-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Effective
					 with dates of service on and after January 1, 1992, an MA eligible nursing
					 facility resident that is in a Medicare benefit period, fully paid days or
					 coinsurance days, or both, is eligible for a maximum of 15 consecutive reserved
					 bed days per hospitalization. The Department will reimburse a nursing facility
					 at 1/3 of the facility's current interim per diem rate on file with the
					 Department, for a hospital reserved bed day when a resident is hospitalized
					 during a Medicare benefit period.
(b) Nursing facilities should follow the
					 billing instructions under the billing section of the Long Term Care Services
					 Provider Handbook when invoicing the Department for hospital reserved bed
					 days.
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.57 - Limitations on payment for prescription drugs

Current through Register Vol. 54, No. 28, July 13, 2024
The Department's interim per diem rate for nursing
						facility care does not include prescription drugs. Prescribed drugs for
						categorically needy are reimbursable directly to a licensed pharmacy according
						to regulations contained in Chapter 1121 (relating to pharmaceutical services).
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.58 - Limitations on payment during strike or disaster situations requiring patient evacuation

Current through Register Vol. 54, No. 28, July 13, 2024
Payment may continue to be made to a facility that has
						temporarily transferred patients, as the result or threat of a strike or
						disaster situation, to the closest medical institution able to meet the
						patients' needs, if the institution receiving the patients is licensed and
						certified to provide the required level of care. If the facility transferring
						the patients can demonstrate that there is no certified facility available for
						the safe and orderly transfer of the patients, the payments may be made so long
						as the institution receiving the patients is certifiable and licensed to
						provide the required level of care. If the facility to which the patients are
						transferred has a different interim per diem rate, the transferring facility
						will be reimbursed at the lower rate. The facility shall immediately notify the
						Department, Office of Medical Assistance Programs, in writing of an impending
						strike or a disaster situation and follow with a listing of MA patients and the
						facility to which they will be or were transferred.
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions); and 55 Pa. Code Chapter 1181 Appendix O (relating to OBRA
						  sanctions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.59 - Payment to a nursing facility for heavy care/intermediate services or intermediate care provided in a dually certified skilled bed

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment may be made to a nursing facility
					 for intermediate care provided in a bed which is dually certified for skilled
					 and intermediate care, subject to the following conditions:
(1) The costs of services to the intermediate
					 care (ICF) patients in dually certified beds, including services to heavy
					 care/intermediate patients, shall be included in the determination of the
					 skilled nursing facility (SNF) payment rate.
(2) The SNF payment rate shall be based on
					 the costs of care of all patients served in dually-certified and SNF-only
					 certified beds.
(3) Except as
					 provided in subsection (b), payments for ICF patients in the dually-certified
					 beds will be determined by the facility's rate for ICF-only certified beds, or,
					 where the facility has no ICF-only certified beds, by combining the facility's
					 SNF rate components for depreciation and interest on capital indebtedness with
					 the lower of one of the following:
(i) The
					 facility's SNF net operating cost rate component.
(ii) The applicable ceiling on ICF net
					 operating costs.
(4) The
					 facility has contacted the Department, prior to invoicing for intermediate care
					 in the bed, to designate the bed as an intermediate care bed for MA program
					 payment purposes.
(5) Payment will
					 not be made for services to an ICF patient in a bed which is not certified to
					 provide intermediate care.