Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1101 - GENERAL PROVISIONS
FEES AND PAYMENTS
Section 1101.64 - Third-party medical resources (TPR)

(a) General. Other private or governmental health insurance benefits shall be utilized before billing the MA Program. Providers shall make reasonable efforts to secure from the recipient sufficient information regarding the primary coverages necessary to bill the insurers or programs. The medical resources which are primary third parties to MA include Medicare; CHAMPUS (Civilian Health and Medical Programs of the Uniformed Services); Blue Cross, Blue Shield or other commercial insurance; VA benefits; Workman's Compensation; and the like. The information needed to bill third parties includes the insurer's name and address, policy or group I.D. number, and the patient's or the patient's employer's address. When the total amount of payment by the third-party resource is less than the Department's fee or rate for the same service, the provider may bill the Department for the difference by submitting an invoice with a copy of the third party's statement of payments attached. If a third-party resource refuses payment to the provider based on coverage exclusions or other reasons, the provider may bill the Department by submitting an invoice with a copy of the third party's refusal advisory attached.

(b) Persons covered by Medicare and MA. If a MA recipient also has Medicare coverage, the Department may be billed for charges that Medicare applied to the deductible or coinsurance, or both. Payment will be made in accordance with established MA rates and fees.