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 1163.451 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 The payment policy established in this section and §§
											1163.452-1163.458 applies to cost
					 reimbursed inpatient services provided by participating hospitals. The
					 Department will reimburse hospitals for the allowable costs they incur in
					 providing compensable cost reimbursed services to MA recipients. As a condition
					 of payment, those services shall meet the requirements of, and be provided
					 within, the limitations in this subchapter and Chapter 1101 (relating to
					 general provisions). The Department will assume responsibility for payment only
					 after other possible sources of payment are exhausted.
(b) The Department will reimburse hospitals
					 for cost items that it determines are allowable under §
											1163.453 (relating to allowable
					 and nonallowable costs).
(c) Prior
					 to a settlement based on audited costs and charges, the Department will pay
					 hospitals an interim per diem rate for inpatient cost reimbursed services
					 provided to MA recipients under §
											1163.452(a)
					 (relating to payment methods and rates).
(d) A final settlement will be made after the
					 hospital's cost report has been audited by the Department of the Auditor
					 General. The final settlement is subject to § 1163.452(c).
(e) The hospital shall submit invoices to the
					 Department in accordance with the instructions in the Provider
					 Handbook.
(f) The readmission of a
					 patient to a hospital within 24 hours of the patient's discharge from the same
					 hospital is not considered a new admission for MA purposes. It is considered a
					 continuation of the original admission.
(g) Payment for preadmission laboratory
					 tests, radiology services and other diagnostic services provided to patients
					 admitted to the hospital will be included in the payment for inpatient
					 services. The hospital may not submit a separate bill for these services. If
					 preadmission diagnostic services are provided to a scheduled inpatient who is
					 not admitted to the hospital as expected, the diagnostic services shall be
					 billed as outpatient services according to the fee schedule in Chapter 1150
					 (relating to MA Program payment policies) and the MA Program Fee
					 Schedule.
(h) For payment to be
					 made for laboratory tests and other diagnostic procedures, the studies shall be
					 related to the patient's condition and be specifically ordered in writing for
					 the particular patient by the attending physician or other licensed
					 practitioner who is responsible for determining the diagnosis or treatment of
					 that patient. In emergency situations, an exception is made to the requirement
					 that studies be specifically ordered in writing if the test or procedure is
					 necessary to prevent the death or serious impairment of the health of the
					 recipient. Payment will not be made for diagnostic services performed pursuant
					 to a preprinted regimen.
(i) The
					 hospital may not seek reimbursement from an MA recipient if certification for
					 days of care is denied by the hospital's utilization review committee or the
					 Department through its Concurrent Hospital Review (CHR) process. If a patient
					 who has been discharged by a physician refuses to leave the hospital at the end
					 of a certified stay, the hospital may bill the recipient for days used beyond
					 the certified length of stay.
(j)
					 The hospital may bill an MA recipient for days of care related to a noncovered
					 service if the recipient was informed, prior to receiving the service, that the
					 particular service and the inpatient care relating to it is not covered under
					 the MA Program.
(k) The hospital
					 may not bill the MA Program for services provided to a person who has applied
					 for MA benefits unless the CAO has notified the hospital that the person is
					 eligible for MA benefits.
(l) If a
					 hospital voluntarily terminates the provider agreement, payment for inpatient
					 hospital services continues, for MA patients admitted prior to the date on
					 which the facility announced its intent to withdraw from the Program, until the
					 effective date of the termination. Departmental payment will stop for services
					 provided on and after the effective date of the termination of the provider
					 agreement.
(m) If a patient is
					 admitted to the distinct part, medical rehabilitation or drug and alcohol
					 detoxification/rehabilitation unit of a general hospital from the emergency
					 room, the services provided in the emergency room shall be billed on the
					 inpatient invoice.
(n) Except as
					 specified in subsection (o), cost-reimbursed services and items provided to an
					 inpatient shall be billed as inpatient services.
(o) The following services and items may not
					 be billed as inpatient services:
(1) Direct
					 care services provided by salaried practitioners.
(2) Ambulance services for:
(i) Patients transferred from the emergency
					 room or clinic of a hospital to another hospital for admission.
(ii) Inpatients discharged from one hospital,
					 transferred by ambulance to another hospital and then admitted by the second
					 hospital.