Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › INSURER CLAIMS PROCESSING › Section 69.43 - Insurer payment requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For
					 Part A providers, the payment shall be 110% of the Medicare reimbursement
					 allowance plus, when applicable, the estimated pass-through costs and
					 applicable cost or day outliers which are facility specific as calculated by
					 the intermediaries. An insurer is not required to maintain an open claim file
					 until final settlement of the pass-through costs and outliers. A claim file may
					 be closed upon payment of the estimated pass-through costs and outliers. The
					 estimated pass-through costs should be submitted by the provider at the time of
					 billing. Neither a provider nor an insurer may seek to reopen closed claims or
					 bill upon final settlement of the pass-through costs and outliers. A provider
					 may seek payment for these amounts if an insurer has not paid for the estimated
					 pass-through costs and outliers.
(b) If a Medicare fee schedule exists for
					 out-patient, rehabilitation and physician services, insurers shall pay Part A
					 and B providers at 110%. If the Medicare reimbursement allowance is the
					 Medicare aggregate payment, in areas such as out-patient services,
					 rehabilitation services, and home health care services, payment shall be 110%
					 of the actual cost based upon the cost-to-charge ratios for each ancillary,
					 out-patient, or other reimbursable cost center service utilized by the insured.
					 When an ancillary cost center's services consist of a combined fee schedule and
					 a blended payment, insurers shall pay 110% of the fee schedule amount plus 110%
					 of the actual cost based upon the cost-to-charge ratio payment for the
					 ancillary cost center. Payment for in-patient rehabilitation services shall
					 consist of the routine cost per diem (room and board) plus the actual cost
					 based upon the cost-to-charge ratio of each ancillary cost center service times
					 110%. Payment for out-patient rehabilitation services shall be the actual cost
					 based upon the cost-to-charge ratio for each ancillary cost center service
					 times 110%. The costs used to develop these payments shall be based upon the
					 latest audited Medicare cost report for that facility.
(c) An insurer shall pay the provider's usual
					 and customary charge for services rendered when the charge is less than 110% of
					 the Medicare payment or a different allowance as may be determined under §
											69.12(b)
					 (relating to exemption from payment limitations). An insurer shall pay 80% of
					 the provider's usual and customary charge for services rendered if no Medicare
					 payment exists. In calculating the usual and customary charge, an insurer may
					 utilize the requested payment amount on the provider's bill for services or the
					 data collected by the carrier or intermediaries to the extent that the data is
					 made available.
(d) An insurer
					 shall provide a complete explanation of the calculations made in computing its
					 determination of the amount payable including whether the calculation is based
					 on 110% of the Medicare payment, 80% of the usual and customary charge or at a
					 different allowance determined by the Commissioner under §
											69.12(b). A bill
					 submitted by the provider delineating the services rendered and the information
					 from which a determination could be made by the insurer as to the appropriate
					 payment amount will not be construed as a demand for payment in excess of the
					 permissible payment amount.
This section cited in 31 Pa. Code §
													69.22 (relating to billing
						  procedures).