Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.48 - Noncompensable services and items

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will not pay an inpatient
				  psychiatric facility for:
(1) Experimental
				  procedures and services that are not in accordance with customary standards of
				  medical practice or that are not commonly used.
(2) A day of inpatient care solely for the
				  purpose of performing diagnostic tests that can be performed on an outpatient
				  basis, or tests not related to the diagnoses that require the inpatient
				  hospital care.
(3) A day of
				  inpatient care if payment is available from another public agency or another
				  insurance or health program.
(4)
				  Services not ordinarily provided to the general public.
(5) Methadone maintenance.
(6) Days of care during which the patient was
				  absent from the inpatient psychiatric facility to attend school, conferences or
				  meetings, to participate in other activities outside the facility, or for
				  employment except for therapeutic leave under §
											1151.43 (relating to limitations
				  on payment).
(7) Custodial care
				  related or unrelated to court commitments. Payment for services provided to
				  recipients confined to an inpatient psychiatric facility under a court
				  commitment for any reason will be made only if medical necessity exists for
				  psychiatric inpatient care.
(8)
				  Diagnostic or therapeutic procedures for experimental research or educational
				  purposes.
(9) Unnecessary
				  admissions and days of care due to conditions which do not require psychiatric
				  inpatient care, such as, rest cures and room and board for relatives during a
				  recipient's hospitalization.
(10)
				  Days of care for recipients who no longer require psychiatric inpatient care.
				  The Department does make payment to an inpatient psychiatric facility for
				  skilled nursing or intermediate care provided for a recipient in a certified
				  bed in a certified and approved hospital-based skilled nursing or intermediate
				  care unit in accordance with Chapter 1181 (relating to nursing facility care)
				  or successor provisions.
(11) Days
				  of care for recipients remaining in an inpatient psychiatric facility beyond
				  the length of stay certified by the Department's Concurrent Hospital Review
				  (CHR) unit, or, if the hospital has been granted an exemption to the CHR
				  process, days of care beyond the length of stay certified by the hospital's
				  utilization review committee.
(12)
				  Grace periods, such as pending discharge of a recipient when inpatient hospital
				  care is no longer needed.
(13) Days
				  of care due to failure to promptly request or perform necessary diagnostic
				  studies or consultations.
(14) Days
				  of care on or after the effective date of a court commitment to another
				  facility.
(15) Days of inpatient
				  care provided to a recipient who is suitable for an alternate type or level of
				  care, regardless of whether the recipient is under voluntary or involuntary
				  commitment.
(16) Diagnostic
				  procedures or laboratory tests not specifically ordered by the physician or
				  practitioner responsible for the diagnosis or treatment of the patient unless
				  the procedure or test is necessary to prevent the death or serious impairment
				  of the patient's health.
(17)
				  Diagnostic procedures or laboratory tests ordered by means of a stamped or
				  preprinted regimen.
(18) The day of
				  discharge unless it is also the day of admission.
(19) Days of care not certified in accordance
				  with the Department's concurrent hospital review process unless the inpatient
				  psychiatric facility has been granted an exemption by the Department.
(20) Days of care due to failure to promptly
				  apply for a court-ordered commitment.