Current through Register Vol. 54, No. 44, November 2, 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.
(b) The Department will not pay inpatient
psychiatric facilities for services or items provided in conjunction with the
provision of a service or item in subsection (a).
(c) The Department will not pay inpatient
psychiatric facilities for services or items in subsection (a) even if the
attending physician or hospital utilization review committee determines that
the stay was medically necessary.
The provisions of this §1151.48 amended under sections 201
and 443.1(1) of the Public Welfare Code (62 P. S.
§§
201 and
443.1(1)).
This section cited in 55 Pa. Code §
1151.45 (relating to nonallowable
costs); and 55 Pa. Code §
1151.74 (relating to
responsibilities of the inpatient psychiatric facility utilization review
committee).
