reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.42 - Payment methods and rates

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will pay inpatient
				  psychiatric facilities a payment rate based on cost items that are determined
				  to be allowable under §
										1151.44 (relating to allowable
				  costs).
(b) The Auditor General
				  will audit each inpatient psychiatric facility's cost report to determine
				  allowable costs under State and Federal regulations.
(c) Out-of-State private psychiatric
				  hospitals are reimbursed under §
										1151.50 (relating to payment for
				  out-of-State private psychiatric hospital services).
(d) Payment for inpatient hospital services,
				  including acute care general hospitals and their district part units, private
				  psychiatric hospitals and freestanding rehabilitation hospitals, will not be
				  made in excess of the amount which would be paid in the aggregate for those
				  services under Medicare principles of reimbursement in 42 CFR Part 413
				  (relating to principles of reasonable cost reimbursement; payment for end-stage
				  renal disease services).
The provisions of this §
												1151.42 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 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.43 - Limitations on payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For
				  adult recipients, payment for inpatient psychiatric hospital services in a
				  private psychiatric hospital or a distinct part of a psychiatric unit of a
				  general hospital is limited to 30 days per fiscal year.
(b) 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.
(c) The Department is authorized to grant an
				  exception to the limits specified in subsection (a) as described in §
				  1101.31(f) (relating to scope).
The provisions of this §
												1151.43 amended under sections
						201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code
						(62
						P. S. §§
													201(2),
						403(b), 443.1, 443.3, 443.6,
						448 and 454).
This section cited in 55 Pa. Code §
												1151.48 (relating to
						noncompensable services and items).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.44 - Allowable costs

Current through Register Vol. 54, No. 28, July 13, 2024
The Department uses Medicare principles as established by
					 the Social Security Act (42
					 U.S.C.A. §§
											301-1399)
					 and Federal regulations and instructions as a basis for determining what cost
					 items are allowable for the purposes of MA reimbursement. In addition to the
					 cost items allowable under 42 CFR Part 413 (relating to principles of
					 reasonable cost reimbursement; payment for end-stage renal disease services),
					 the Department recognizes costs for direct or indirect chaplaincy expenses
					 related to patient care excluding training costs associated with the chaplaincy
					 program.
The provisions of this §
												1151.44 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 §
												1151.42 (relating to payment
						methods and rates).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.45 - Nonallowable costs

Current through Register Vol. 54, No. 28, July 13, 2024
Costs not allowable under the MA Program are:
(1) Costs exceeding the limits established by
				  the Department of Health and Human Services under Medicare regulations at
				  42 CFR
				  413.30 (relating to limitations on
				  reimbursable costs).
(2) Costs
				  related to the provision of a noncompensable service or item listed in §
										1151.48 (relating to
				  noncompensable services and items).
(3) Inpatient costs related to preadmission
				  laboratory tests, radiology services and other diagnostic services provided to
				  recipients who are not admitted to the hospital as planned.
(4) Costs for legal services relating to
				  litigation against the Commonwealth, including administrative appeals, if the
				  litigation is ultimately decided in favor of the Commonwealth.
(5) Costs for relocating or housing
				  employes.
(6) Costs for which
				  Federal financial participation (FFP) is precluded by statute, except as may be
				  expressly provided for otherwise in this chapter.
(7) Capital costs related to new or
				  additional beds unless an application for a Certificate of Need for the new or
				  additional beds has been approved by the Department of Health, with an
				  effective date of June 30, 1991, or earlier. For the facility to receive
				  payment, the project shall be substantially implemented as defined by
				  applicable Department of Health regulations within the effective period of the
				  Certificate of Need.
(8) Capital
				  costs related to new or additional beds unless a letter of nonreviewability has
				  been issued on or before June 30, 1991.
(9) Capital costs for replacement beds,
				  unless the facility received a Certificate of Need as defined at section 701 of
				  the Health Care Facilities Act (35 P. S. §
											448.701) for replacement beds. To be
				  recognized as allowable, the replacement beds shall physically replace beds in
				  the same facility, capital costs related to the beds being replaced shall have
				  been recognized as allowable and the project shall be substantially implemented
				  as defined by applicable Department of Health regulations within the effective
				  period of the original Section 1122 approval or the original Certificate of
				  Need, plus one 6-month extension period.
The provisions of this §
												1151.45 amended under sections 201
						and 443.1(1) and (4) of the Public Welfare Code (62 P. S. §§
													201 and
						443.1(1) and
						(4)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.46 - Payment rate calculations for Fiscal Years 1993-94 and 1994-95

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The amount of
				  the Department's payment for services provided to an MA recipient is the
				  inpatient psychiatric facility's per diem rate established under this section
				  multiplied by the number of compensable days of service rendered minus payment
				  made by a third-party payor, the recipient or a legally responsible relative.
				  The Department will also deduct from the payment Medicare Part B payments and
				  other resources available to the patient to meet the cost of the inpatient
				  psychiatric care.
(b) The per diem
				  rate includes payments for capital costs and for direct medical education
				  costs, but does not include disproportionate share payments.
(c) The method for determining the per diem
				  payment rates under this section depends upon the status of the inpatient
				  psychiatric provider as being "existing" or "new," as follows:
(1) An "existing" provider is an inpatient
				  psychiatric facility that was enrolled in the MA Program for the entire period
				  from July 1, 1989, to June 30, 1990, including each inpatient psychiatric
				  facility which changed ownership after July 1, 1989, and elected to retain the
				  rate of the prior entity, which had submitted a full cost report for Fiscal
				  Year 1989-90.
(2) A "new" provider
				  is an inpatient psychiatric facility that enrolled in the MA Program after July
				  1, 1989, including each inpatient psychiatric facility which changed ownership
				  between July 1, 1989, and June 30, 1993, and elected to have its payment rate
				  rebased.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.47 - Annual cost reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
				  inpatient psychiatric facility shall complete Form MA 336 (Financial Report for
				  Hospital and Hospital Health Care Complex Under the Medical Assistance Program
				  of the Department of Human Services, Commonwealth of Pennsylvania) in
				  accordance with Medicare principles at 42 CFR Part 405 , Subpart D (relating to
				  principles of reimbursement for services by hospital based
				  physicians).
(b) The inpatient
				  psychiatric facility shall submit Form MA 336 to the Department's Office of
				  Medical Assistance Programs by September 30 of each year. The Department may
				  grant a 30-day extension to the September 30 due date, upon receipt of a
				  written request from a private psychiatric hospital or a general hospital with
				  a distinct part psychiatric unit. If the inpatient psychiatric facility
				  participates in Medicare, a completed copy of Form HCFA-2552-
Hospital,
				  Hospital-Skilled Nursing Facility Complex and Skilled Nursing Facility Cost
				  Report
-also shall be submitted to the Department as a supplement to
				  Form MA 336.
(c) The hospital's
				  cost report shall:
(1) Be prepared using the
				  accrual method of accounting.
(2)
				  Cover a fiscal period of 12-consecutive months, from July 1 to June 30, except
				  as noted in paragraph (4).
(3)
				  Include information necessary for the proper determination of costs payable
				  under the Program, including financial records and statistical data.
(4) In the case of a hospital beginning
				  operations after the start of the fiscal year, cover the period from the date
				  of approval for participation in the MA Program to the end of that fiscal
				  year.
(5) Be adjusted to remove the
				  costs of direct care by salaried physicians and other salaried
				  practitioners.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.49 - Third-party liability

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Inpatient psychiatric facilities shall utilize the available third-party
				  resources for services a recipient receives while in the inpatient psychiatric
				  facility.
(b) If expected payment
				  by a third-party resource is not realized, the inpatient psychiatric facility
				  may bill the MA Program.
(c) If the
				  psychiatric facility receives reimbursement from a third-party subsequent to
				  payment from the Department, the facility 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 facility's invoice, the facility shall submit a copy of the invoice and the
				  request to the Department's Office of Administration at the address specified
				  in the Provider Handbook. The Office of Administration will forward the
				  requested copy to the requestor and take follow-up action necessary to ensure
				  the repayment of MA expenditures.
(e) If a recipient is entitled to Medicare
				  Part A benefits, the Department will pay the amount of the Medicare deductible
				  and coinsurance minus other resources available to the recipient for the
				  psychiatric inpatient care.
(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
				  lesser of the following:
(1) The inpatient
				  psychiatric facility's per diem rate multiplied by the number of compensable
				  inpatient psychiatric days of care rendered, minus resources available to the
				  recipient for hospital care, including Medicare Part B payments.
(2) The amount of the insurance plan's
				  deductible and coinsurance minus other resources available to the recipient for
				  inpatient psychiatric care, including Medicare Part B payments.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.50 - Payment for out-of-State private psychiatric hospital services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
				  will pay for compensable services furnished by out-of-State private psychiatric
				  hospitals to an eligible Pennsylvania recipient, if one of the following
				  exists:
(1) Residents in a given area
				  generally receive their care in a particular out-of-State private psychiatric
				  hospital; this would apply when the out-of-State private psychiatric hospital
				  is closer to, or substantially more accessible from the residence of the
				  recipient than, the nearest private psychiatric hospital within this
				  Commonwealth which is adequately equipped and is available for the treatment of
				  the individual's illness.
(2)
				  Documentation is provided verifying one of the following:
(i) The recipient required inpatient
				  psychiatric hospital services on an emergency basis, while temporarily out of
				  this Commonwealth.
(ii) An
				  out-of-State private psychiatric 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 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.52 - Payment for capital costs not included in the base year

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Inpatient psychiatric facilities which
				  place a new capital project into service after the base year, as determined
				  under §
										1151.46 (relating to payment rate
				  calculations for Fiscal Years 1993-94 and 1994-95), are entitled to payment for
				  certain capital costs, if the qualifying criteria, outlined under this section,
				  are met.
(b) This additional
				  payment applies only to capital projects with an approval date of either a
				  Certificate of Need or letter of nonreviewability on or before June 30,
				  1991.
(c) To apply for an
				  additional capital payment, an inpatient psychiatric facility shall submit
				  documentation sufficient to enable the Department to verify that the
				  requirements of this section are met.
(d) To be eligible for an additional capital
				  payment, the costs related to a capital project shall meet the following
				  criteria:
(1) The costs shall represent
				  increases in the inpatient psychiatric facility's allowable depreciation and
				  interest costs for a fixed asset that was entered in the inpatient psychiatric
				  facility's fixed asset ledger in the year being audited.
(2) The costs shall be attributable to a
				  fixed asset that is both of the following:
(i) Approved for Certificate of Need on or
				  before June 30, 1991, under 28 Pa. Code Chapter 301 or 401 (relating to
				  limitations on Federal participation for capital expenditures; and Certificate
				  of Need Program), or not subject to review for Certificate of Need as evidenced
				  by a letter of nonreviewability dated on or before June 30, 1991.
(ii) Related to patient care in accordance
				  with Medicare standards.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.53 - Billing requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  inpatient psychiatric facility shall submit invoices to the Department under
				  the instructions in the Provider Handbook.
(b) The Department will not pay for inpatient
				  psychiatric services if the facility submits the invoice for payment for those
				  services later than 180 days following the last certified day of care unless
				  the hospital is awaiting one of the following:
(1) Final determination of the patient's
				  eligibility for a potential third-party payment.
(2) Final determination by the CAO of the
				  patient's eligibility for MA.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT CONDITIONS FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.61 - Payment conditions: general

Current through Register Vol. 54, No. 28, July 13, 2024
For payment to be authorized for inpatient psychiatric
					 services:
(1) The recipient's need for
				  admission shall be certified under §
										1151.62 (relating to Certification
				  of Need for admission).
(2) A
				  medical and psychiatric evaluation shall be made by the attending physician or
				  staff physician under §
										1151.63 (relating to medical and
				  psychiatric evaluation).
(3) A
				  social evaluation must be made under §
										1151.64 (relating to social
				  evaluation) by one of the following:
(i) The
				  social service staff of the CAO or its agent for recipients applying for
				  admission to an inpatient psychiatric facility.
(ii) An appropriate member of the inpatient
				  psychiatric facility's staff, if the individual applies for MA while in an
				  inpatient psychiatric facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT CONDITIONS FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.62 - Certification of Need for admission

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If a recipient is 21 years of age or
				  older, the attending or staff physician shall certify in the medical record
				  either at the time of admission or on the first day of a benefit period, when
				  applicable, or upon application for MA, that acute psychiatric services in a
				  private psychiatric hospital are needed.
(b) If a recipient under 21 years of age is
				  being admitted, an independent team shall certify at the time of admission the
				  need for acute psychiatric services in a private psychiatric hospital and
				  document this in the medical record. The team shall:
(1) Include a physician.
(2) Have competence in diagnosis and
				  treatment of mental illness, preferably in child psychiatry.
(3) Have knowledge of an individual's
				  situation.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT CONDITIONS FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.63 - Medical and psychiatric evaluation

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The medical and psychiatric evaluation of
				  each applicant's and recipient's need for inpatient psychiatric care shall
				  include the following:
(1)
				  Diagnoses.
(2) Summary of present
				  medical findings.
(3) Medical
				  history.
(4) Mental and physical
				  functional capability.
(5)
				  Prognoses.
(6) A recommendation by
				  a physician concerning admission to an inpatient psychiatric facility or
				  continued care in the inpatient psychiatric facility, whichever is
				  applicable.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT CONDITIONS FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.64 - Social evaluation

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  social evaluation of an applicant or recipient shall include the following:
(1) Reports of interviews with the
				  patient.
(2) Reports of interviews
				  with family members or other individuals familiar with the patient, if
				  applicable.
(3) An assessment of
				  home plans and family attitudes, if applicable.
(4) Community resource contacts.
(5) A social history.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT CONDITIONS FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.65 - Plan of care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Before
				  authorization for payment for care provided to a recipient 21 years of age or
				  older, the attending or staff physician shall establish, and include in the
				  recipient's medical record, an individual written plan of care. The plan of
				  care shall be designed to maintain the recipient at or restore the recipient to
				  the greatest possible degree of health and independent functioning. The plan
				  shall include:
(1) Diagnoses, symptoms,
				  complaints and complications indicating the need for admission.
(2) Treatment objectives.
(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) Special procedures recommended for the
				  health and safety of the patient.
(6) Plans for continuing care, including
				  review and modification to the plan of care.
(7) Plans for discharge.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT CONDITIONS FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.66 - Team developing plan of care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The team responsible for developing the
				  plan of care for recipients under age 21 shall be capable of:
(1) Assessing the recipient's immediate and
				  long range therapeutic needs, developmental priorities and personal strengths
				  and liabilities.
(2) Assessing the
				  potential resources of the recipient's family to care for and support the
				  recipient.
(3) Setting treatment
				  objectives.
(4) Prescribing
				  therapeutic modalities to achieve the plan's objectives.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT CONDITIONS FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.67 - Payment conditions related to the recipient's continued need for care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For MA payments
				  to be made on behalf of a recipient for continuing care in a private
				  psychiatric hospital:
(1) The plan of care at
				  §
											1151.65 (relating to plan of care)
				  shall be reviewed within 14 days after admission to determine whether inpatient
				  psychiatric services are or were needed and to make necessary changes in the
				  plan. Review of the plan of care shall be carried out by:
(i) The team specified in §
												1151.66 (relating to team
				  developing plan of care), if the recipient is 20 years of age or
				  younger.
(ii) The attending or
				  staff physician and other personnel involved in the recipient's care, if the
				  recipient is 21 years of age or older.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.70 - Scope of claim review process

Current through Register Vol. 54, No. 28, July 13, 2024
Inpatient psychiatric services provided to MA recipients
					 are subject to the utilization review procedures in this chapter and in Chapter
					 1101 (relating to the general provisions).
The provisions of this §
												1151.70 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 §
												1151.61 (relating to payment
						conditions: general); and 55 Pa. Code §
												1151.67 (relating to payment
						conditions related to the recipient's continued need for
						care).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.71 - Concurrent hospital review

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Each inpatient psychiatric facility shall conduct reviews of each MA
				  recipient's need for admission and continued need for psychiatric inpatient
				  services in accordance with the Department's Manual for Concurrent Hospital
				  Review (CHR) unless granted an exemption by the Department.
(b) The Department will regularly monitor
				  each inpatient psychiatric facility's utilization review program to determine
				  whether it is operating in accordance with the CHR process and this section.
				  Monitoring is carried out through review of admissions, continued stays,
				  patient records and claims paid by the Department.
(c) The Department will approve or disapprove
				  the recipient's need for admission and need for continued hospitalization
				  through its CHR process unless an exemption is granted by the
				  Department.
(d) If a discrepancy
				  exists between a hospital's utilization review plan and the instructions in the
				  Department's
Manual for Concurrent Review of Inpatient Hospital
				  Services
, the Department's manual shall take precedence.
The provisions of this §
												1151.71 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 §
												1151.61 (relating to payment
						conditions: general); and 55 Pa. Code §
												1151.67 (relating to payment
						conditions related to the recipient's continued need for
						care).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.72 - Inpatient psychiatric facility utilization review plan

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each inpatient psychiatric facility
				  participating in the MA Program shall have in effect a written utilization
				  review plan which provides for the review of each recipient's need for
				  inpatient psychiatric services. Each provider's utilization review plan shall
				  provide for a utilization review committee which meets the requirements under
				  §
										1151.73 (relating to requirements
				  for inpatient psychiatric utilization review committees).
(b) Each utilization review plan shall
				  describe the organization, composition and functions of the utilization review
				  committee and specify the frequency of the meetings of the committee.
(c) Each utilization review plan shall
				  provide for a review of each recipient's admission to the inpatient psychiatric
				  facility under §
										1151.75 (relating to admission
				  review requirements).
(d) Each
				  utilization review plan shall provide for a review of each recipient's
				  continued stay in the inpatient psychiatric facility under §
										1151.76 (relating to continued
				  stay review requirements).
(e) Each
				  utilization review plan shall describe the methods the utilization review
				  committee uses to select and conduct medical care evaluation studies under
				  §
										1151.77 (relating to medical care
				  evaluation studies).
The provisions of this §
												1151.72 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 §
												1151.61 (relating to payment
						conditions: general); and 55 Pa. Code §
												1151.67 (relating to payment
						conditions related to the recipient's continued need for
						care).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.73 - Requirements for inpatient psychiatric utilization review committees

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each inpatient
				  psychiatric facility shall have a utilization review committee composed of two
				  or more physicians knowledgeable in the diagnosis and treatment of mental
				  diseases and other professional personnel as required under
				  42 CFR
				  456.206 (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 utilization review
				  committee may not participate in the review of a patient's case if the member
				  is or was directly responsible for the care of that patient.
(c) A member of the utilization review
				  committee may not have a direct or indirect financial interest in a
				  hospital.
The provisions of this §
												1151.73 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 §
												1151.61 (relating to payment
						conditions: general); 55 Pa. Code §
												1151.67 (relating to payment
						conditions related to the recipient's continued need for care); and 55 Pa. Code
						§
												1151.72 (relating to inpatient
						psychiatric facility utilization review
						plan).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.74 - Responsibilities of the inpatient psychiatric facility utilization review committee

Current through Register Vol. 54, No. 28, July 13, 2024
The utilization review committee, or its representative,
					 shall:
(1) Conduct admission reviews
				  in accordance with §
										1151.75 (relating to admission
				  review requirements).
(2) Conduct
				  continued stay reviews in accordance with §
										1151.76 (relating to continued
				  stay review requirements).
(3)
				  Conduct medical care evaluation studies in accordance with §
										1151.77 (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 Review of Inpatient Hospital Services.
(5) Provide that each recipient's record
				  include:
(i) Identification of the
				  recipient.
(ii) Copies of the
				  certification of days records.
(iii) The names 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 plan of care required under §
				  1151.65 (relating to plan of care).
(vi) Initial and subsequent review dates
				  specified in accordance with this chapter.
(vii) Justification of the recipient's need
				  for admission and need for continued inpatient hospital services as documented
				  by the attending physician.
(viii)
				  The reasons and plan for continued stay, if the physician believes continued
				  stay is necessary.
(ix) Other
				  supporting material the utilization review committee believes
				  appropriate.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.76 - Continued stay review requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The utilization review committee or its
				  representative shall review the need for continued stay of each recipient
				  admitted to the inpatient psychiatric facility.
(b) The 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
				  shall be more extensive for 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 utilization review committee or its
				  representative shall assess the need for continued stay in an inpatient
				  psychiatric facility by comparing each case to the written criteria established
				  under subsection (b).
(d) The
				  utilization review committee or its representative shall assign subsequent
				  review dates based on the date continued hospitalization will no longer be
				  necessary.
(e) The utilization
				  review committee or its representative 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 before the
				  expiration of the previously assigned length of stay.
(f) If an individual applies for MA while in
				  an inpatient psychiatric facility, the committee shall:
(1) Assign the continued stay review date
				  within 1 working day after the inpatient psychiatric facility is notified that
				  the individual has applied for MA.
(2) Contact the Department's Concurrent
				  Hospital Review section for approval of the assigned length of stay.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.77 - Medical care evaluation studies

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The 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 inpatient psychiatric facility and, when indicated, make
				  recommendations for changes that would be beneficial to patients, staff, the
				  facility and the community.
(c) MCE
				  studies shall include analysis of at least the following:
(1) Admissions.
(2) Durations of stay.
(3) Diagnostic categories.
(4) Ancillary services, including drugs and
				  biologicals.
(5) Professional
				  services performed in the facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.78 - Adverse determinations

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  The utilization review committee shall send an adverse determination letter on
				  each case for which it denies admission or denies continued stay. The letter
				  shall be sent to:
(1) The recipient.
(2) The recipient's next of kin or sponsor,
				  if applicable.
(3) The attending
				  physician.
(4) The inpatient
				  psychiatric facility administrator.
(5) The Office of MA Programs.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › INSPECTIONS OF CARE › Section 1151.81 - Inspections of care: general

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  The Department's Federally required inspection of care team will evaluate the
				  care and services provided to each recipient under 21 years of age or 65 years
				  of age or older in a participating psychiatric hospital at least annually by
				  making an onsite inspection. The hospital will be notified no earlier than 48
				  hours prior to the inspection and advised of the scheduled arrival of the team.
				  The hospital shall make MA medical records readily available to the team. The
				  team's inspection includes:
(1) Personal
				  contact with, and observation of, each recipient under 21 years of
				  age.
(2) Review of a recipient's
				  medical record.
(3) Personal
				  contact with and observation of the recipient if the recipient is 65 years of
				  age or older and the medical record contains incomplete reports.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › INSPECTIONS OF CARE › Section 1151.82 - Inspections of care reports

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  inspection of care team will submit reports on each inspection of care within
				  45 days following the inspection to:
(1) The
				  hospital administrator along with a copy for the chairperson of the utilization
				  review committee.
(2) The Office of
				  Mental Health of the Department.
(3) The CAO, if recommendations are made for
				  alternate placement.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › ADMINISTRATIVE SANCTIONS › Section 1151.91 - Provider abuse

Current through Register Vol. 54, No. 28, July 13, 2024
If the Department determines that a provider has billed for
					 services inconsistent with this part, provided services outside the scope of
					 customary standards of medical practice, or otherwise violated the standards
					 set forth in the provider agreement, the provider is subject to the sanctions
					 in Chapter 1101 (relating to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › ADMINISTRATIVE SANCTIONS › Section 1151.92 - Administrative sanctions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) 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 stay.
(b) If the utilization review committee fails
				  to conduct a continued stay review or fails to notify the Department on or
				  before the expiration of the previously assigned length of stay, the Department
				  will not certify facility days between the expiration of the previously
				  assigned length of stay and the date the request for continued stay is made and
				  approved.
(c) If the Department
				  determines that services or items provided by the facility were not medically
				  justified or were unnecessary, inappropriate or otherwise noncompensable, the
				  Department will deny payment for those services as well as services and items
				  related to the provision of that service or item. Payment will also be denied
				  to the practitioner.
The provisions of this §
												1151.92 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 1151 - INPATIENT PSYCHIATRIC SERVICES › PROVIDER RIGHT OF APPEAL › Section 1151.101 - Provider right of appeal

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Providers have the right to appeal adverse actions of the Department under
				  Chapter 1101 (relating to general provisions).
(b) Inpatient psychiatric facilities and
				  practitioners do not have the right to a separate appeal on the same
				  case.
(c) If an inpatient
				  psychiatric facility appeals a decision by the Department to fully or partially
				  deny payment for a case, the Department will withhold the denied payments
				  pending decision on the appeal.
The provisions of this §
												1151.101 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 1153 - OUTPATIENT PSYCHIATRIC SERVICES › GENERAL PROVISIONS › Section 1153.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
The MA Program provides payment for specific medically
					 necessary psychiatric outpatient clinic services, MMHT services and psychiatric
					 outpatient partial hospitalization services rendered to eligible MA
					 beneficiaries by psychiatric outpatient clinics and psychiatric outpatient
					 partial hospitalization facilities enrolled as providers under the program.
					 Payment for behavioral health services is subject to the provisions of this
					 chapter, Chapter 1101 (relating to general provisions) and the limitations
					 established in Chapter 1150 (relating to MA Program payment policies) and the
					 MA Program Fee Schedule.
The provisions of this §
												1153.1 amended under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › COVERED AND NONCOVERED SERVICES › Section 1153.11 - Types of services covered

Current through Register Vol. 54, No. 28, July 13, 2024
Medical Assistance Program coverage for psychiatric
					 outpatient clinics, partial hospitalization outpatient facilities and MMHT
					 services is limited to professional medical and psychiatric services for the
					 diagnosis and treatment of mental illness or emotional disturbance, including a
					 mental illness or emotional disturbance along with an intellectual disability,
					 as specified in the MA Program Fee Schedule provided by psychiatric outpatient
					 clinic providers and psychiatric outpatient partial hospitalization providers
					 to MA beneficiaries.
The provisions of this §
												1153.11 amended under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › COVERED AND NONCOVERED SERVICES › Section 1153.12 - Outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
The psychiatric outpatient clinic services specified in the
					 MA Program Fee Schedule and the psychiatric partial hospitalization outpatient
					 services specified in the MA Program Fee Schedule are covered only when
					 provided by licensed psychiatric outpatient clinics or psychiatric partial
					 hospitalization outpatient facilities under the direction of a psychiatrist.
					 MMHT services specified in the MA Program Fee Schedule are covered only when
					 provided by a licensed psychiatric outpatient clinic that has an approved
					 service description for MMHT. Payment is subject to the conditions and
					 limitations established in this chapter and Chapter 1101 (relating to general
					 provisions).
The provisions of this §
												1153.12 amended under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › SCOPE OF BENEFITS › Section 1153.21 - Scope of benefits for children under 21 years of age

Current through Register Vol. 54, No. 28, July 13, 2024
Children under 21 years of age are eligible for the full
					 range of covered psychiatric outpatient clinic, MMHT and psychiatric partial
					 hospitalization services in the MA Program Fee Schedule.
The provisions of this §
												1153.21 amended under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › SCOPE OF BENEFITS › Section 1153.22 - Scope of benefits for adults 21 years of age or older

Current through Register Vol. 54, No. 28, July 13, 2024
Adults 21 years of age or older are eligible for the full
					 range of covered psychiatric outpatient clinic, MMHT and psychiatric partial
					 hospitalization services in the MA Program Fee Schedule.
The provisions of this §
												1153.22 amended under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › SCOPE OF BENEFITS › Section 1153.23 - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
The provisions of this §
												1153.23 reserved under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › SCOPE OF BENEFITS › Section 1153.24 - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
The provisions of this §
												1153.24 reserved under section
						201(2) of the Human Services Code (62 P.S. §
													201(2)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › PROVIDER PARTICIPATION › Section 1153.41a - Medication prescription-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
Medications may be prescribed by a certified registered
					 nurse practitioner in outpatient psychiatric clinics and outpatient partial
					 hospitalization facilities as authorized under 49 Pa. Code Chapter 18,
					 Subchapter C (relating to certified registered nurse practitioners) and Chapter
					 21, Subchapter C (relating to certified registered nurse practitioners).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1153 - OUTPATIENT PSYCHIATRIC SERVICES › PROVIDER PARTICIPATION › Section 1153.42 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Responsibilities of
				  providers
. Ongoing responsibilities of providers are established in
				  Chapter 1101 (relating to general provisions). Psychiatric outpatient clinics
				  and psychiatric partial hospitalization outpatient facilities shall also adhere
				  to the additional requirements established in this section.
(b)
Recordkeeping
				  requirements
. In addition to the requirements listed in §
										1101.51(e)
				  (relating to ongoing responsibilities of providers), the following items must
				  be included in the records of MA beneficiaries receiving psychiatric outpatient
				  clinic, MMHT and psychiatric partial hospitalization outpatient services:
(1) The treatment plan must include:
(i) The treatment plan goals.
(ii) Services to be provided to the
				  individual by the psychiatric outpatient clinic or partial hospitalization
				  outpatient facility or through referral.
(iii) Persons to directly provide each
				  service.