Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES
PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES
Section 1151.53 - Billing requirements

Universal Citation: 55 PA Code ยง 1151.53

Current through Register Vol. 54, No. 44, November 2, 2024

(a) The inpatient psychiatric facility shall submit invoices to the Department under the instructions in the Provider Handbook.

(b) The Department will not pay for inpatient psychiatric services if the facility submits the invoice for payment for those services later than 180 days following the last certified day of care unless the hospital is awaiting one of the following:

(1) Final determination of the patient's eligibility for a potential third-party payment.

(2) Final determination by the CAO of the patient's eligibility for MA.

(c) The Department will not pay for claims or claim adjustments, including pended claims and pended claim adjustments for services provided during Fiscal Year 1983-84, if they are not adjudicated by December 31, 1984. Beginning with Fiscal Year 1984-85, exception requests for prior fiscal year services will not be considered through the exception process, but may be appealed upon completion of the audit. This subsection applies whether or not the hospital was granted an extension under subsection (b).

(d) Except as specified in subsection (e), inpatient psychiatric facilities shall bill services and items provided to an inpatient as inpatient services.

(e) Inpatient psychiatric facilities may not bill for the following services and items provided to a patient of the facility:

(1) Services provided by a practitioner, unless the practitioner is under salary or contract with the inpatient psychiatric facility to provide services; or services provided by a practitioner who may bill directly under another chapter.

(2) Services provided by a midwife, as defined in § 1142.2 (relating to definitions), unless the midwife is under salary or contract with the inpatient psychiatric facility to provide services.

(3) Orthoses, prostheses and durable medical equipment.

(4) Ambulance services when one or more of the following applies:
(i) The ambulance is not owned and operated directly by the private psychiatric hospital, or general hospital of which the psychiatric unit is a part.

(ii) The patient is transferred from the emergency room or clinic of the private psychiatric hospital, or general hospital of which a psychiatric unit is a part, to another inpatient psychiatric facility for admission.

(iii) The patient is discharged from the inpatient psychiatric facility, transferred by ambulance to another inpatient psychiatric facility and then admitted to the second inpatient psychiatric facility.

(f) If a patient is admitted to the distinct part psychiatric unit of a general hospital from the emergency room, the psychiatric unit shall bill for the services provided in the emergency room on the inpatient invoice.

The provisions of this §1151.53 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201 and 443.1(1)).

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