Current through Register Vol. 54, No. 45, November 9, 2024
Section 1163.451 - General payment policy(a) The payment policy established in this section and §§ 1163.452-1163.458 applies to cost reimbursed inpatient services provided by participating hospitals. The Department will reimburse hospitals for the allowable costs they incur in providing compensable cost reimbursed services to MA recipients. As a condition of payment, those services shall meet the requirements of, and be provided within, the limitations in this subchapter and Chapter 1101 (relating to general provisions). The Department will assume responsibility for payment only after other possible sources of payment are exhausted.(b) The Department will reimburse hospitals for cost items that it determines are allowable under § 1163.453 (relating to allowable and nonallowable costs).(c) Prior to a settlement based on audited costs and charges, the Department will pay hospitals an interim per diem rate for inpatient cost reimbursed services provided to MA recipients under § 1163.452(a) (relating to payment methods and rates).(d) A final settlement will be made after the hospital's cost report has been audited by the Department of the Auditor General. The final settlement is subject to § 1163.452(c).(e) The hospital shall submit invoices to the Department in accordance with the instructions in the Provider Handbook.(f) The readmission of a patient to a hospital within 24 hours of the patient's discharge from the same hospital is not considered a new admission for MA purposes. It is considered a continuation of the original admission.(g) Payment for preadmission laboratory tests, radiology services and other diagnostic services provided to patients admitted to the hospital will be included in the payment for inpatient services. The hospital may not submit a separate bill for these services. If preadmission diagnostic services are provided to a scheduled inpatient who is not admitted to the hospital as expected, the diagnostic services shall be billed as outpatient services according to the fee schedule in Chapter 1150 (relating to MA Program payment policies) and the MA Program Fee Schedule.(h) For payment to be made for laboratory tests and other diagnostic procedures, the studies shall be related to the patient's condition and be specifically ordered in writing for the particular patient by the attending physician or other licensed practitioner who is responsible for determining the diagnosis or treatment of that patient. In emergency situations, an exception is made to the requirement that studies be specifically ordered in writing if the test or procedure is necessary to prevent the death or serious impairment of the health of the recipient. Payment will not be made for diagnostic services performed pursuant to a preprinted regimen.(i) The hospital may not seek reimbursement from an MA recipient if certification for days of care is denied by the hospital's utilization review committee or the Department through its Concurrent Hospital Review (CHR) process. If a patient who has been discharged by a physician refuses to leave the hospital at the end of a certified stay, the hospital may bill the recipient for days used beyond the certified length of stay.(j) The hospital may bill an MA recipient for days of care related to a noncovered service if the recipient was informed, prior to receiving the service, that the particular service and the inpatient care relating to it is not covered under the MA Program.(k) The hospital may not bill the MA Program for services provided to a person who has applied for MA benefits unless the CAO has notified the hospital that the person is eligible for MA benefits.(l) If a hospital voluntarily terminates the provider agreement, payment for inpatient hospital services continues, for MA patients admitted prior to the date on which the facility announced its intent to withdraw from the Program, until the effective date of the termination. Departmental payment will stop for services provided on and after the effective date of the termination of the provider agreement.(m) If a patient is admitted to the distinct part, medical rehabilitation or drug and alcohol detoxification/rehabilitation unit of a general hospital from the emergency room, the services provided in the emergency room shall be billed on the inpatient invoice.(n) Except as specified in subsection (o), cost-reimbursed services and items provided to an inpatient shall be billed as inpatient services.(o) The following services and items may not be billed as inpatient services:(1) Direct care services provided by salaried practitioners.(2) Ambulance services for: (i) Patients transferred from the emergency room or clinic of a hospital to another hospital for admission.(ii) Inpatients discharged from one hospital, transferred by ambulance to another hospital and then admitted by the second hospital.The provisions of this §1163.451 adopted June 22, 1984, effective 7/1/1984, 14 Pa.B. 2185; amended through October 9, 1986, effective retroactively to July 1, 1984, 16 Pa.B. 3828; amended September 30, 1988, effective 10/1/1988, 18 Pa.B. 4418; amended June 16, 1989, effective immediately and applies retroactively to July 1, 1988, 19 Pa.B. 2563; amended December 14, 1990, effective 1/1/1991, 20 Pa.B. 6164; amended June 18, 1993, effective 7/1/1993, 23 Pa.B. 2917; amended October 29, 1993, effective 7/1/1993, 23 Pa.B. 5241.The provisions of this §1163.451 amended under section 443.1(1) of the Public Welfare Code (62 P. S. § 443.1(1)); and Articles I-XI and XIV of the Public Welfare Code (62 P. S. §§ 101-1411).
The section cited in 55 Pa. Code § 1163.451a (relating to clarification of the term "in writing"-statement of policy); and 55 Pa. Code § 1163.457 (relating to payment policies relating to out-of-State hospitals).