reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.111 - Inpatient acute care providers-DRG payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payments to providers of inpatient
					 hospital services, whose Medicare Program payments are based on DRGs, shall be
					 calculated by multiplying the established DRG payment on the date of discharge
					 by 113%.
(b) For discharges on and
					 before December 31, 1994, the DRG payments, using the Medicare DRG methodology,
					 shall be based on the most recently published tables of payments, relative
					 values, wage indices, geographic adjustment factors, rural and urban
					 designations and other applicable Medicare payment adjustments published in the
Federal Register
. The effective date for these changes under
					 the Medicare Program shall also be the effective date for the changes under the
					 act.
(c) If the amount of the DRG
					 reimbursement changes during a patient's stay, the applicable reimbursement
					 rate on the date of discharge shall be used to calculate payment under the
					 act.
(d) If a patient was admitted
					 prior to August 31, 1993, the act's medical fee caps may not apply.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.154 (relating to medical fee
						  updates on and after January 1, 1995-inpatient acute care providers subject to
						  DRGs plus add-on payments).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.112 - Inpatient acute care providers-capital-related costs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An additional payment shall be made to
					 providers of inpatient hospital services for the capital-related costs
					 reimbursed under the Medicare Part A Program.
(b) Hospitals, which have a hospital-specific
					 capital rate lower than the Federal capital rate (fully-prospective), shall be
					 paid for capital-related costs as follows: the hospital's capital rate, as
					 determined by the Medicare intermediary, shall be multiplied by the DRG
					 relative weight on the date of discharge.
(c) Hospitals, which have a hospital-specific
					 capital rate equal to or higher than the Federal capital rate (hold-harmless),
					 shall be paid for capital-related costs as follows:
(1) Hospitals paid at 100% of the Federal
					 capital rate shall receive the Federal capital rate, as determined by the
					 Medicare intermediary, multiplied by the DRG relative weight on the date of
					 discharge.
(2) Hospitals paid at a
					 rate greater than 100% of the Federal capital rate shall be paid on the basis
					 of the most recent notice of interim payment rates as determined by the
					 Medicare intermediary. Hospitals shall receive the new Federal capital rate
					 multiplied by the DRG relative weight on the date of the discharge plus the old
					 Federal capital rate as determined by the Medicare intermediary.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.113 - Inpatient acute care providers-medical education costs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Providers of inpatient hospital services
					 shall receive an additional payment in recognition of the costs of medical
					 education as provided pursuant to an approved teaching program and as
					 reimbursed under the Medicare Program. For providers with an approved teaching
					 program in place prior to January 1, 1995, the medical education add-on payment
					 shall be based on the following calculations:
(1) Payments for direct medical education
					 costs shall be based on figures from the latest audited Medicare cost report
					 and calculated as follows: the medical education cost (Worksheet E, Part IV,
					 Column 1, Line 18) shall be divided by total hospital DRG payments (Worksheet
					 E, Part A, Column 1). This amount shall then be multiplied by the DRG payment
					 on the date of discharge.
(2)
					 Payments for indirect medical education costs shall be calculated as follows:
					 the add-on percentage, identified in the provider's latest Medicare interim
					 rate notification, multiplied by the DRG payment on the date of
					 discharge.
(3) Payments for
					 paramedical education costs shall be calculated by determining the ratio of
					 Medicare paramedical education costs to Medicare DRG payments. This ratio shall
					 then be multiplied by the DRG payment on the date of discharge. The necessary
					 ratio shall be computed as follows:
(i) If the
					 most recently audited Medicare cost report is for a fiscal year beginning on or
					 after October 1, 1991, and uses HCFA Form 2552-92, then the ratio shall be
					 determined by taking the sum of Lines 14 and 15 on Worksheet E, Part A and
					 dividing it by Line 1.
(ii) If the
					 most recently audited Medicare cost report is for a fiscal year beginning
					 before October 1, 1991, and uses HCFA Form 2552-89, then the ratio shall be
					 determined by taking the sum of medical education costs from Worksheet D, Part
					 I, Column 5, Line 101 and Worksheet D, Part II, Column 5, Line 101 and dividing
					 the sum by total charges from Worksheet D, Part II, Column 7, Line 101;
					 multiplying this amount by Medicare charges from Worksheet D, Part II, Column
					 9, Line 101; and dividing this amount by DRG payments from Worksheet E, Part A,
					 Line 1.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.114 - Inpatient acute care providers-outliers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payments for cost outliers shall be based
					 on the Medicare method for determining eligibility for additional payments as
					 follows: the billed charges will be multiplied by the aggregate ratio of
					 cost-to-charges obtained from the most recently audited Medicare cost report to
					 determine the cost of the claim. This cost of claim shall be compared to the
					 applicable Medicare cost threshold. Cost in excess of the threshold shall be
					 multiplied by 80% to determine the additional cost outlier payment.
(b) Payments to acute care providers, when
					 the length of stay exceeds the Medicare thresholds ("day outliers"), shall be
					 determined by applying the Medicare methodology as follows: the DRG payment
					 plus the capital payments shall be divided by the arithmetic mean of length of
					 stay for that DRG as determined by HCFA to arrive at a per diem payment rate.
					 This rate shall be multiplied by the number of actual patient days for the
					 claim which are in excess of the outlier threshold as determined by HCFA and
					 published in the
Federal Register.
The result is added to the
					 DRG payment.
(c) When the
					 calculations under both subsections (a) and (b) are greater than zero, the
					 outlier payment shall be limited to the lesser of the cost outlier computed in
					 accordance with subsection (a) or the day outlier computed in accordance with
					 subsection (b).
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.154 (relating to medical fee
						  updates on or after January 1, 1995-inpatient acute care providers subject to
						  DRGs plus add-on payments).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.115 - Inpatient acute care providers-disproportionate-share hospitals

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An additional
					 payment shall be made to providers of inpatient hospital services designated by
					 the Medicare Program as disproportionate-share hospitals.
(b) Payments to disproportionate-share
					 hospitals shall be calculated as follows: the add-on percentage identified in
					 the provider's latest Medicare interim rate notification shall be multiplied by
					 the DRG payment on the date of discharge and then multiplied by 113%.
(c) A provider requesting additional payments
					 under the act based on its Medicare designation as a disproportionate-share
					 hospital shall provide evidence of this designation to the insurer.
(d) If a hospital loses its right to receive
					 additional payments as a disproportionate-share hospital under the Medicare
					 Program prior to January 1, 1995, it shall also lose its right to receive
					 additional payments under the act.
(e) Loss of the disproportionate-share
					 designation on and after January 1, 1995, will not result in the loss of this
					 designation for purposes of determining payments under the act.
(f) If a hospital gains the
					 disproportionate-share designation on and after January 1, 1995, it will not be
					 paid according to that designation under the act.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.154 (relating to medical fee
						  updates on and after January 1, 1995-inpatient acute care providers subject to
						  DRGs plus add-on payments).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.116 - Inpatient acute care providers-Medicare-dependent small rural hospitals, sole-community hospitals and Medicare-geographically reclassified hospitals

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payments for
					 Medicare-dependent small rural hospitals, sole-community hospitals and
					 Medicare-geographically reclassified hospitals, shall be calculated as follows:
					 the hospital's payment rate identified on the latest Medicare interim rate
					 notice shall be multiplied by the DRG payment on the date of discharge and then
					 multiplied by 113%.
(b) A provider
					 requesting additional payments under the act based on one of the special
					 designations in subsection (a) shall provide evidence of this Medicare
					 designation to the insurer.
(c) If
					 a hospital loses its designation as a Medicare-dependent small rural hospital,
					 sole-community hospital or Medicare-geographically reclassified hospital under
					 the Medicare Program prior to January 1, 1995, it shall also lose the
					 designation and the right to receive additional payments under the
					 act.
(d) Loss of one of the special
					 designations in subsection (a) on and after January 1, 1995, will not result in
					 the loss of the designation for purposes of determining payments under the
					 act.
(e) If a hospital gains
					 designation as a Medicare-dependent small rural hospital, sole-community
					 hospital or Medicare-geographically reclassified hospital under the Medicare
					 Program on and after January 1, 1995, it will not be paid according to that
					 designation under the act.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.154 (relating to medical fee
						  updates on and after January 1, 1995-inpatient acute care providers subject to
						  DRGs plus add-on payments).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.117 - Outpatient acute care providers, specialty hospitals and other cost-reimbursed providers not subject to the Medicare fee schedule

Current through Register Vol. 54, No. 28, July 13, 2024
The following services shall be paid on a cost-reimbursed
						basis for medical treatment rendered under Act 44:
(1) Outpatient services of general acute care
					 providers and specialty hospitals reimbursed by Medicare using the HCFA Form
					 2552 or any successor form.
(2)
					 Inpatient services provided in specialty hospitals and distinct part
					 rehabilitation and psychiatric units of general acute care hospitals, which are
					 exempt from the DRG reimbursement methodology and are reimbursed by Medicare
					 using the HCFA Form 2552 or any successor form.
(3) Services provided in Comprehensive
					 Outpatient Rehabilitation Facilities reimbursed by Medicare using the HCFA Form
					 2088 or any successor form.
(4)
					 Services provided in outpatient therapy centers electing cost reimbursement for
					 Medicare using the HCFA Form 2088 or any successor form.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.118 (relating to
						  RCCs-generally); 34 Pa. Code §
													127.119 (relating to payments for
						  services using RCCs); 34 Pa. Code §
													127.120 (relating to
						  RCCs-comprehensive outpatient rehabilitation facilities (CORFs) and outpatient
						  physical therapy centers); 34 Pa. Code §
													127.126 (relating to new
						  providers); 34 Pa. Code §
													127.155 (relating to medical fee
						  updates on and after January 1, 1995-outpatient acute care providers, specialty
						  hospitals and other cost-reimbursed
						  providers).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.118 - RCCs-generally

Current through Register Vol. 54, No. 28, July 13, 2024
Payments for services listed in §
											127.117 (relating to outpatient
						acute care providers, specialty hospitals and other cost reimbursed providers
						not subject to the Medicare fee schedule) shall be based on the provider's
						specific Medicare departmental RCC for the specific services or procedures
						performed. For treatment rendered on and before December 31, 1994, the
						provider's latest audited Medicare cost report, with an NPR date preceding the
						date of service, shall provide the basis for the RCC.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.107 (relating to outpatient
						  providers subject to Medicare fee schedule-physical therapy centers and
						  independent physical therapists).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.119 - Payments for services using RCCs

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Payments for services listed in §
											127.117(1)
					 (relating to outpatient acute care providers, specialty hospitals and other
					 cost reimbursed providers not subject to the Medicare fee schedule) shall be
					 calculated as follows: the provider charge shall be multiplied by the
					 applicable RCC, which then shall be multiplied by 113%.
(b) The RCC to be used for providers
					 receiving payment for outpatient services under the RCC methodology shall be
					 the same RCC used by the Medicare Program for determining reimbursement. For
					 providers with audited cost reports using HCFA Form 2552-89 or earlier,
					 Worksheet C, Part II, Column 10 is to be used. For providers with audited cost
					 reports using HCFA Form 2552-92, Worksheet C, Part II, Column 8 is to be
					 used.
(c) Payments for inpatient
					 services listed in §
											127.117(2) shall
					 be calculated as follows:
(1) Inpatient
					 routine services shall be reimbursed based on the inpatient routine cost per
					 diem from the most recently audited Medicare cost report, HCFA Form 2552-89 or
					 2552-92, Worksheet D-1, Part II, Line 38. The routine cost per diem shall be
					 updated by the TEFRA (Tax Equity and Fiscal Responsibility Act of 1982) target
					 rate of increase as published by HCFA in the
Federal Register
.
					 The applicable update shall be applied cumulatively based on the annual update
					 factors published subsequent to the date of the audited cost report year end
					 and prior to December 31, 1994.
(2)
					 Inpatient ancillary services shall be reimbursed based on the provider charge
					 multiplied by the applicable RCC, which then shall be multiplied by
					 113%.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.120 - RCCs-comprehensive outpatient rehabilitation facilities (CORFs) and outpatient physical therapy centers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except as
					 noted in subsection (c), payments for services listed in §
											127.117(3) and (4)
					  (relating to outpatient acute care
					 providers, specialty hospitals and other cost reimbursed providers not subject
					 to the Medicare fee schedule) relating to CORFs and outpatient physical therapy
					 centers, shall be calculated as follows: the provider's charge shall be
					 multiplied by the applicable RCC which then shall be multiplied by
					 113%.
(b) In situations where the
					 most recent audited Medicare cost report is for the fiscal year ending on or
					 after April 30, 1993, and where the CORF or outpatient physical therapy center
					 is reimbursed by Medicare using the HCFA Form 2088-92, the RCC to be used for
					 the calculation in subsection (a) shall be the same RCC used by the Medicare
					 Program for determining reimbursements at Worksheet C, Column 2.
(c) In situations where the most recent
					 audited cost report is for the fiscal year ending before April 30, 1993, and
					 where the CORF or outpatient physical therapy center is reimbursed by Medicare
					 using the HCFA 2088 form, the payment method to be used shall be as follows:
(1) For providers whose basis of Medicare
					 apportionment is gross charges, the RCC shall be developed by dividing the
					 total departmental cost for each therapy department on line 4 of Schedule C and
					 by the total charges for each therapy department on line 1 of Schedule C.
					 Payments then shall be calculated in accordance with subsection (a).
(2) For providers whose basis of Medicare
					 apportionment is therapy visits, the payment rate shall be based on the average
					 cost per visit, developed by dividing the total departmental cost for each
					 therapy department on line 4 of Schedule C by the total visits for each therapy
					 department on line 1 of Schedule C. Payments for services shall then be
					 calculated as follows: the average cost per visit shall be multiplied by the
					 billed number of visits and then multiplied by 113%.
(3) For providers whose basis of Medicare
					 apportionment is weighted units, the payment rate shall be based on the average
					 cost per weighted unit, developed by dividing the total departmental cost for
					 each therapy department on line 4 of Schedule C by the total weighted units for
					 each therapy department on line 1 of Schedule C. Payments for services shall
					 then be calculated as follows: the average cost per weighted unit shall be
					 multiplied by the billed units and then multiplied by 113%.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.121 - Cost-reimbursed providers-medical education costs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Cost-reimbursed providers shall receive
					 an additional payment in recognition of the costs of medical education as
					 provided pursuant to an approved teaching program, and as reimbursed under the
					 Medicare Program. For providers with an approved teaching program in place
					 prior to January 1, 1995, the medical education add-on payment shall be
					 calculated as follows, using figures from the most recently audited Medicare
					 cost report:
(1) The hospital's outpatient
					 medical education to Medicare outpatient cost ratio shall be determined by
					 taking the outpatient medical education cost from Supplemental Worksheet E-3,
					 Part IV, Column 1, Line 19, and dividing it by the Medicare outpatient cost
					 from Supplemental Worksheet E-3, Part IV, Column 1, Line 13.03. This ratio
					 shall then be multiplied by the provider's charges, multiplied by the
					 applicable RCC.
(2) The hospital's
					 inpatient medical education to Medicare inpatient cost ratio shall be
					 determined by taking the inpatient medical education cost from Supplemental
					 Worksheet E-3, Part IV, Column 1, Line 18, and dividing it by the Medicare
					 inpatient cost from Supplemental Worksheet E-3, Part IV, Column 1, Line 12.05.
					 This ratio shall then be multiplied by the provider's charges, multiplied by
					 the applicable RCC.
(3) Payments
					 for the cost of indirect medical education are included in the RCC payment and
					 are not to be calculated as a separate item.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.122 - Skilled nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
Payments to providers of skilled nursing care who file
						Medicare cost reporting forms HCFA 2540 (freestanding facilities) or HCFA 2552
						(hospital based facilities), or any successor forms, shall be calculated as
						follows: the most recent Medicare interim per diem rate shall be multiplied by
						the number of patient days and then multiplied by 113%.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.156 (relating to medical fee
						  updates on and after January 1, 1995-skilled nursing
						  facilities).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.123 - Hospital-based and freestanding home health care providers

Current through Register Vol. 54, No. 28, July 13, 2024
Payments to providers of home health care who file an
						HCFA Form 1728 (freestanding facilities) or an HCFA Form 2552 (hospital-based
						facilities), or any successor forms, shall be calculated as follows: the per
						visit limitation as determined by the Medicare Program multiplied by 113%. If
						the usual and customary charge per visit is lower than this calculation, then
						payment shall be limited to the usual and customary charge per visit. Payment
						at 113% of the Medicare limit shall represent payment for the entire service
						including all medical supplies and other items subject to cost reimbursement by
						the Medicare Program.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.157 (relating to medical fee
						  updates on and after January 1, 1995-home health care
						  providers).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.124 - Outpatient and end-stage renal dialysis payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payments to providers of outpatient and
					 end-stage renal dialysis shall be calculated as follows: the Medicare composite
					 rate, per treatment, shall be multiplied by 113%.
(b) Hospital outpatient ancillary services
					 paid outside of the Medicare composite rate shall be reimbursed in accordance
					 with §
											127.119 (relating to payments for
					 services using RCCs).
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.158 (relating to medical fee
						  updates on and after January 1, 1995-outpatient and end-stage renal
						  dialysis).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.125 - ASCs

Current through Register Vol. 54, No. 28, July 13, 2024
Payments to providers of outpatient surgery in an ASC,
						shall be based on the ASC payment groups defined by HCFA, and shall include the
						Medicare list of covered services and related classifications in these groups.
						This payment amount shall be multiplied by 113%. For surgical procedures not
						included in the Medicare list of covered services, payments shall be based on
						80% of the usual and customary charge.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); and 34 Pa. Code §
													127.159 (relating to medical fee
						  updates on and after January 1,
						  1995-ASCs).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.126 - New providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) New
					 providers who are receiving payments in accordance with §
											127.103 or §
											127.120 (relating to outpatient
					 providers subject to the Medicare fee schedule-generally; and
					 RCCs-comprehensive outpatient rehabilitation facilities (CORFs) and outpatient
					 physical therapy centers) shall bill and receive payments beginning with the
					 treatment of their first workers' compensation patient.
(b) New providers who are receiving payments
					 in accordance with §
											127.117 (relating to outpatient
					 acute care providers, speciality hospitals and other cost-reimbursed providers
					 not subject to the Medicare fee schedule) shall receive payments calculated as
					 follows:
(1) Commencing with the date the
					 provider begins treating its first patient until the completion and filing of
					 the first Medicare cost report, payment shall be based on the aggregate RCC
					 using the most recent Medicare interim rate notification.
(2) Within 30 days of the filing of the first
					 cost report a new provider shall submit to the Bureau a copy of the detailed
					 charge master in effect at the conclusion of the first cost report year and a
					 copy of the filed cost report. Upon receipt of the filed cost report, payments
					 shall be made in accordance with §
												127.119 (relating to payments for
					 services using RCCs), using the filed RCCs. The detailed charge master will be
					 frozen in accordance with §
												127.155 (relating to medical fee
					 updates on and after January 1, 1995-outpatient acute care providers, specialty
					 hospitals and other cost reimbursed providers).
(3) Upon receipt of the NPR, payments shall
					 be made in accordance with § 127.119.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.127 - Mergers and acquisitions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) When a
					 merger, acquisition or change in ownership results in the elimination of the
					 assets of a merged or acquired entity, and consolidation of the assets into the
					 surviving entity, payments shall be determined by reference to the relevant
					 cost reports and other relevant data of the surviving entity, except as noted
					 in subsection (b).
(b) If services
					 were provided at the merged or acquired provider that were not provided at the
					 surviving provider (prior to merger or acquisition) and therefore were not
					 reported as a cost center on its most recently audited Medicare cost report,
					 the per diem rates and RCCs to be used for determining payment for these
					 services shall be obtained from the most recently audited cost report of the
					 merged or acquired provider.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.128 - Trauma centers and burn facilities-exemption from fee caps

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Acute care provided in a trauma center or
					 a burn facility is exempt from the medical fee caps, and shall be paid based on
					 100% of usual and customary charges if the following apply:
(1) The patient has an immediately
					 life-threatening injury or urgent injury.
(2) Services are provided in an acute care
					 facility that is one of the following:
(i) A
					 level I or level II trauma center, accredited by the Pennsylvania Trauma
					 Systems Foundation under the Emergency Medical Services Act (35 P. S.
					 §§
														6921-6938).
(ii) A burn facility which meets the service
					 standards of the American Burn Association.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.129 - Out-of-State medical treatment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 When injured employes are treated outside of this Commonwealth by providers who
					 are licensed by the Commonwealth to provide health care services, the
					 applicable medical fee cap shall be as follows:
(1) If the provider is both licensed by and
					 has a place of business within this Commonwealth, the medical fees shall be
					 capped based on the Medicare reimbursement rate applicable under the Medicare
					 Program for services rendered at the provider's primary place of business in
					 this Commonwealth, subject to §
												127.152 (relating to medical fee
					 updates on and after January 1, 1995-generally).
(2) If the provider is licensed by the
					 Commonwealth to provide health care services but does not have a place of
					 business within this Commonwealth, medical fees shall be capped based on the
					 Medicare reimbursement rate applicable in Harrisburg, Pennsylvania, under the
					 Medicare Program for the services rendered subject to §
												127.152.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.130 - Special reports

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payments
					 shall be made for special reports (CPT code 99080) only if these reports are
					 specifically requested by the insurer. Office notes and other documentation
					 which are necessary to support provider codes billed may not be considered
					 special reports.
(b) Payments for
					 special reports shall be at 80% of the provider's usual and customary
					 charge.
(c) The Bureau-prescribed
					 report required by §
											127.203 (relating to medical
					 bills-submission of medical reports) may not be considered a special report
					 that is chargeable under this section.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.131 - Payments for prescription drugs and pharmaceuticals-generally

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payments for
					 prescription drugs and professional pharmaceutical services shall be limited to
					 110% of the average wholesale price (AWP) of the product.
(b) Pharmacists and insurers may reach
					 agreements on which Nationally recognized schedule shall be used to define the
					 AWP of prescription drugs. The Bureau in resolving payment disputes, may use
					 any of the Nationally recognized schedules to determine the AWP of prescription
					 drugs. The Bureau will provide information by an annual notice in the
Pennsylvania Bulletin
as to which of the Nationally recognized
					 schedules it is using to determine the AWP of prescription drugs.
(c) Pharmacists may not bill, or otherwise
					 hold the employe liable, for the difference between the actual charge for the
					 prescription drugs and pharmaceutical services and 110% of the AWP of the
					 product.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.132 - Payments for prescription drugs and pharmaceuticals-direct payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Insurers may
					 enter into agreements with pharmacists authorizing pharmacists to bill the cost
					 of prescription drugs directly to the insurer.
(b) When agreements are reached under
					 subsection (a), insurers shall promptly notify injured employes of the names
					 and locations of pharmacists who have agreed to directly bill and accept
					 payment from the insurer for prescription drugs. However, insurers may not
					 require employes to fill prescriptions at the designated pharmacies.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.133 - Payments for prescription drugs and pharmaceuticals-effect of denial of coverage by insurers

Current through Register Vol. 54, No. 28, July 13, 2024
If an injured employe pays more than 110% of the average
						wholesale price of a prescription drug because the insurer initially does not
						accept liability for the claim under the act, or denies liability to pay for
						the prescription, the insurer shall reimburse the injured employe for the
						actual cost of the prescription drugs, once liability has been admitted or
						determined.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.134 - Payments for prescription drugs and pharmaceuticals-ancillary services of health care providers

Current through Register Vol. 54, No. 28, July 13, 2024
A pharmacy or pharmacist owned or employed by a health
						care provider, which is recognized and reimbursed as an ancillary service by
						Medicare, and which dispenses prescription drugs to individuals during the
						course of treatment in the provider's facility, shall receive payment under the
						applicable Medicare reimbursement mechanism multiplied by
						113%.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › CALCULATIONS › Section 127.135 - Payments for prescription drugs and pharmaceuticals-drugs dispensed at a physician's office

Current through Register Vol. 54, No. 28, July 13, 2024
(a) When a
					 prescription is filled at a physician's office, payment for the prescription
					 drug shall be limited to 110% of the average wholesale price of the
					 product.
(b) Physicians may not
					 bill, or otherwise hold the employe liable, for the difference between the
					 actual charge for the prescription drug and 110% of the AWP of the
					 product.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.151 - Medical fee updates prior to January 1, 1995-generally

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Changes in Medicare reimbursement rates
					 prior to January 1, 1995, shall be reflected in calculations of payments to
					 providers under the act.
(b) The
					 effective date for these rate changes under the Medicare Program shall also be
					 the effective date for the fee changes under the act. The new rates shall apply
					 to all treatment and services provided on and after the effective date of the
					 rate change.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); and 34 Pa. Code §
													127.103 (relating to outpatient
						  providers subject to the Medicare fee
						  schedule-generally).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.152 - Medical fee updates on and after January 1, 1995-generally

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Changes in
					 Medicare reimbursement rates on and after January 1, 1995, may not be included
					 in calculations of payments to providers under Act 44.
(b) Medical fee updates on and after January
					 1, 1995, shall be calculated based on the percentage changes in the Statewide
					 average weekly wage, as published annually by the Department in the
Pennsylvania Bulletin
. These updates shall be effective on
					 January 1 of each year, and they shall be cumulative.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); 34 Pa. Code §
													127.103 (relating to outpatient
						  providers subject to the Medicare fee schedule-generally); and 34 Pa. Code
						  §
													127.129 (relating to out-of-State
						  medical treatment).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.153 - Medical fee updates on and after January 1, 1995-outpatient providers, services and supplies subject to the Medicare fee schedule

Current through Register Vol. 54, No. 28, July 13, 2024
(a) On and after January 1, 1995, outpatient
					 providers whose payments under the act are based on the Medicare fee schedule
					 under §§
											127.103-127.108 shall be paid as follows:
					 the amount of payment authorized shall be frozen on December 31, 1994, and
					 updated annually by the percentage change in the Statewide average weekly
					 wage.
(b) On and after January 1,
					 1995, adjustments and modifications by HCFA relating to a change in description
					 or renumbering of any HCPCS code will be incorporated into the basis for
					 determining the amount of payment as frozen in subsection (a) for services
					 rendered under the act.
(c) On and
					 after January 1, 1995, payment rates under the act for new HCPCS codes will be
					 based on the rates allowed in the Medicare fee schedule on the effective date
					 of the new codes. These payment rates shall be frozen immediately, and
					 thereafter updated annually by the percentage change in the Statewide average
					 weekly wage.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare); and 34 Pa. Code §
													127.103 (relating to outpatient
						  providers subject to the Medicare fee
						  schedule-generally).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.155 - Medical fee updates on and after January 1, 1995-outpatient acute care providers, specialty hospitals and other cost-reimbursed providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) As of January 1, 1995, providers
					 identified in §
											127.117 (relating to outpatient
					 acute care providers, specialty hospitals and other cost-reimbursed providers
					 not subject to the Medicare fee schedule) shall be paid as follows: as of
					 December 31, 1994, the provider's actual charge by procedure as determined from
					 the detailed charge master, shall be multiplied by the ratio of
					 cost-to-charges, based on the most recently audited Medicare cost report.
					 Except as noted in subsection (b), this amount shall be frozen for purposes of
					 calculating payments under the act and updated annually by the percentage
					 change in the Statewide average weekly wage.
(b) Subsection (a) does not apply in
					 situations where the charge master does not contain unique charges for each
					 item of pharmacy, but instead actual charges are based on algorithms or other
					 mathematical calculations to compute the charge. For purposes of effectuating
					 the freeze, the providers' RCC for pharmacy (drug charges to patients) shall be
					 frozen based on the last audited Medicare cost report as of December 31, 1994.
					 On and after January 1, 1995, the providers' actual charges shall be multiplied
					 by the frozen RCC and then by 113% to determine reimbursements. These payments
					 may not receive fee updates based on changes in the Statewide average weekly
					 wage.
(c) For purposes of
					 effectuating the freeze in reimbursements as provided in subsection (a), the
					 Bureau will calculate the appropriate fee caps for cost-reimbursed providers
					 who are identified in §
											127.117. In order to accomplish
					 this task, the Bureau will utilize information obtained from a complete copy of
					 the provider's detailed charge master by procedure/service codes, HCPCS codes
					 and by applicable Medicare revenue code with rates effective as of September 1,
					 1994, and RCCs from the most recently audited Medicare cost report in effect as
					 of December 31, 1994.
(1) The charge
					 information obtained for purposes of subsection (c) calculations, will remain
					 in the possession of the Bureau. Unless the Bureau obtains the written
					 permission of the provider, the charge information will not be released to
					 anyone other than an authorized representative of the provider.
(2) The Bureau will provide the calculated
					 fees to insurers.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.156 - Medical fee updates on and after January 1, 1995-skilled nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
On and after January 1, 1995, payments to skilled nursing
						facilities shall be as follows: the amount of the payment set forth in §
											127.122 (relating to skilled
						nursing facilities) shall be frozen on December 31, 1994, and updated annually
						by the percentage change in the Statewide average weekly
						wage.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.157 - Medical fee updates on and after January 1, 1995-home health care providers

Current through Register Vol. 54, No. 28, July 13, 2024
On and after January 1, 1995, payments to home health
						care providers shall be as follows: the amount of the payment set forth in
						§
											127.123 (relating to
						hospital-based and freestanding home health care providers) shall be frozen on
						December 31, 1994, and updated annually by the percentage change in the
						Statewide average weekly wage.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.158 - Medical fee updates on and after January 1, 1995-outpatient and end-stage renal dialysis

Current through Register Vol. 54, No. 28, July 13, 2024
On and after January 1, 1995, payments to providers of
						outpatient and end-stage renal dialysis shall be as follows: the amount of the
						payment set forth in §
											127.124 (relating to outpatient
						and end-stage renal dialysis payments) shall be frozen on December 31, 1994,
						and updated annually by the percentage change in the Statewide average weekly
						wage.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.159 - Medical fee updates on and after January 1, 1995-ASCs

Current through Register Vol. 54, No. 28, July 13, 2024
On and after January 1, 1995, payments to providers of
						outpatient surgery in ASCs shall be as follows: the amount of the payment in
						§
											127.125 (relating to ASCs) shall
						be frozen on December 31, 1994, and updated annually by the percentage change
						in the Statewide average weekly wage.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.160 - Medical fee updates on and after January 1, 1995-trauma centers and burn facilities

Current through Register Vol. 54, No. 28, July 13, 2024
Trauma centers and burn facilities shall continue to
						receive their usual and customary charges on and after January 1, 1995, in
						accordance with §
											127.128 (relating to trauma
						centers and burn facilities-exemption from fee caps).
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare).