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 1163.455 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will not pay hospitals for
					 inpatient services directly or indirectly related to or in conjunction with:
(1) Inpatient hospital services provided in
					 conjunction with physicians' services which are identified as outpatient
					 procedures in Chapter 1150 (relating to MA Program payment policies) and the MA
					 Program Fee Schedule unless the procedure is performed as a secondary necessary
					 procedure.
(2) Diagnostic tests and
					 procedures that can be performed on an outpatient basis and diagnostic tests
					 and procedures not related to the diagnoses that require that particular
					 inpatient stay.
(3) Services and
					 items for which full payment is available through Medicare, other financial
					 resources or other health insurance programs.
(4) Services and items not ordinarily
					 provided to the general public.
(5)
					 Periods of absence from the hospital for a purpose such as employment or school
					 attendance except for therapeutic leaves that enable individuals to attend
					 family matters of significant importance. The number of therapeutic leaves
					 during one period of hospitalization is limited under §
												1163.454(c)
					 (relating to limitations on payment).
(6) Diagnostic or therapeutic procedures
					 solely for experimental, research or educational purposes.
(7) Unnecessary admissions and conditions
					 which do not require hospital-type care, such as rest cures and room and board
					 for relatives during a patient's hospitalization.
(8) Inpatient services provided to patients
					 who no longer require acute short-term inpatient hospital care-inappropriate
					 hospital services. For patients who do require skilled nursing or intermediate
					 care, payment will be made to the hospital under Chapter 1181 (relating to
					 nursing facility care) or successor provisions for this care only if the
					 patient is in a certified and approved hospital-based skilled nursing or
					 intermediate care unit.
(9)
					 Inpatient hospital days not certified under the Department's Concurrent
					 Hospital Review (CHR) process or, if the hospital is granted an exemption from
					 CHR, not certified by the hospital's in-house utilization review process. If an
					 MA patient refuses to leave after being discharged by the attending
					 practitioner when the approved length of stay is exhausted, the hospital may
					 bill the patient.
(10) Days of
					 inpatient care due to unnecessary delay in applying for a court-ordered
					 commitment, grace periods, administrative days and custodial care related or
					 unrelated to court commitments or to the child protective services. For
					 purposes of this chapter, custodial care is defined as maintenance, rather than
					 curative care, on an indefinite basis. Grace periods and administrative days
					 relate to days of care while awaiting placement elsewhere.
(11) Inpatient hospital services provided to
					 a recipient by the transferring hospital on or after the effective date of a
					 court commitment to another facility.
(12) Days of inpatient hospitalization due to
					 the failure to promptly request or perform necessary diagnostic studies,
					 medical-surgical procedures or consultations.
(13) Friday or Saturday admissions unless one
					 of the following occurs:
(i) The admission is
					 an emergency as documented in the patient's medical record by the admitting
					 physician.
(ii) The medical or
					 surgical procedure for which the patient was admitted is performed on the day
					 of or the day following admission.
(14) The day of discharge from inpatient
					 hospital care except for same calendar day admissions and discharges.
(15) A day of inpatient hospital care
					 provided to a recipient whose medical condition makes the person suitable for
					 an alternate level of care.
(16)
					 Drug or alcohol, or both, detoxification and rehabilitation or rehabilitation
					 services in an inpatient facility unless one of the following circumstances
					 exists:
(i) Complications exist, or there is a
					 reasonable expectation of complications, that require inpatient facility
					 medical treatment, including:
(A) An
					 individual requires acute inpatient treatment based on the presence of a major
					 medical complication or a significant psychiatric problem, or an individual has
					 a history of significant substance abuse and a complication as described in
					 §
														1163.59(d)(1)(i), (ii), (iii) or
					 (iv) (relating to noncompensable services,
					 items and outlier days).
(B) An
					 individual in residential care exhibits significant medical or psychiatric
					 complications as described in §
														1163.59(d)(1)(i), (ii), (iii) or
					 (iv), and requires more intensive treatment
					 and observation.
(ii)
					 Detoxification has been certified by the Department and completed in an acute
					 care general hospital, and the patient is discharged directly from the acute
					 care general hospital where the detoxification occurred to the inpatient
					 hospital rehabilitation setting.
(iii) A nonhospital, medically appropriate
					 bed is not available within a 50-mile radius of the inpatient hospital to which
					 the patient presents for drug or alcohol detoxification or rehabilitation
					 services and the inpatient hospital rehabilitation facility includes
					 documentation of the nonavailability of the nonhospital bed in the medical
					 record. A nonhospital bed will be considered to be not available if the
					 medically appropriate nonhospital facility has no beds available or refuses to
					 accept the patient.