Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1163 - INPATIENT HOSPITAL SERVICES
Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM
PAYMENT FOR HOSPITAL SERVICES
Section 1163.51 - General payment policy

(a) Except for services provided in a hospital unit excluded from the DRG prospective payment system, the Department will pay a prospective rate for inpatient hospital services compensable under the MA Program. See § 1163.2 (relating to definitions) for the definition of "inpatient hospital services." The Department will base the prospective payment on the DRG into which the patient is classified and on the prospective payment rate assigned to a hospital.

(b) In addition to the DRG prospective payment made by the Department for a patient discharged from the hospital, the Department will reimburse a participating hospital for:

(c) If a hospital stay meets the requirements for outliers in § 1163.56 (relating to outliers), the prospective payment amount is adjusted under that section.

(d) A hospital that qualifies for disproportionate share payments under § 1163.67 (relating to disproportionate share payments) receives monthly payments as provided under that section.

(e) When provided to an inpatient, the Department makes separate payment to a hospital for:

(f) The Department does not pay for an admission that it determines is not medically necessary.

(g) The Department's prospective payment amount is payment in full for compensable inpatient hospital services. Compensable services provided to an inpatient are covered by the Department's payment, except for direct care services provided by salaried practitioners and midwives.

(h) Except as specified in subsection (i), no payment for inpatient hospital services is made until the recipient is discharged from the hospital. A recipient is considered discharged from the hospital if one of the following occurs:

(i) A hospitalization for a continuous period of 90 days or longer may be billed, and paid, on an interim basis. Specific procedures for interim billing and payment are specified in the Inpatient Hospital Handbook issued to providers by the Department.

(j) Payment for emergency room services provided to patients admitted to the hospital is included in the payment for inpatient hospital services. The hospital may not submit a separate bill for these services.

(k) A hospital may not bill an MA recipient for care related to a noncovered service unless the recipient was informed, prior to receiving the service, that the service and the inpatient care relating to it were not covered under the MA Program.

(l) A hospital may not bill the MA Program for services provided to a person who has made application for MA benefits unless the CAO has notified the hospital that the person is eligible for MA benefits.

(m) If a hospital voluntarily terminates the provider agreement, payment for inpatient hospital services is made for MA patients admitted prior to the effective date of the termination of the provider agreement.

(n) If a hospital provides services to a recipient with a psychiatric principal diagnosis but the hospital does not have a psychiatric unit that is excluded from the prospective payment system under § 1163.32, the Department pays a 2-day per diem amount for the hospital stay. The 2-day per diem amount is determined by dividing the normal payment rate for the DRG by the Statewide average length of stay for the DRG and multiplying the result by two.

(o) If a hospital provides services to a recipient with a psychiatric principal diagnosis and the hospital has a psychiatric unit that is excluded from the prospective payment system under § 1163.32, the Department makes payment for these services under Subchapter B (relating to hospitals and hospital units under cost reimbursement principles). The Department makes no payment for the hospital stay under the DRG prospective payment system unless an emergency situation exists and the psychiatric unit is full, in which case the Department will make a 2-day per diem payment determined by dividing the payment rate for the DRG by the Statewide average length of stay for the DRG and multiplying the result by two.

(p) If a hospital provides services to a recipient with a drug or alcohol principal diagnosis but the hospital's drug and alcohol services have not been approved by the Department of Health, Office of Drug and Alcohol Programs, the Department pays a 2-day per diem amount for the hospital stay. The 2-day per diem amount is determined by dividing the normal payment rate for the DRG by the Statewide average length of stay for the DRG and multiplying the result by two.

(q) Except as specified in subsection (r), if a hospital provides services to a recipient with a drug and alcohol principal diagnosis and the hospital has been approved by the Department of Health, Office of Drug and Alcohol Programs to provide detoxification services, the Department pays the full DRG rate for the hospital stay.

(r) If a hospital provides services to a recipient with a drug or alcohol principal diagnosis and the hospital has a drug and alcohol rehabilitation unit that is excluded from the prospective payment system under § 1163.32, the Department makes no payment for the hospital stay under the DRG prospective payment system. For these hospitals, payment for services provided to a recipient with a drug or alcohol principal diagnosis is made under Subchapter B.

(s) The Department will not pay an acute care hospital for medical rehabilitation services which are not provided in conjunction with acute care services. For recipients receiving only medical rehabilitation services and requiring no acute care services, payment is made only to distinct part medical rehabilitation units or freestanding medical rehabilitation hospitals enrolled in the MA Program under Subchapter B.

(t) Payment for inpatient hospital services, including acute care general hospitals and their distinct part units, private psychiatric hospitals and freestanding rehabilitation hospitals, will not be made in excess of the amount which would be paid in the aggregate for those services under Medicare principles of reimbursement in 42 CFR Part 413 (relating to principles of reasonable cost reimbursement; payment for end-stage renal disease services).

(u) Capital and operating costs related to new or additional beds are nonallowable for purposes of this subchapter unless a Certificate of Need or letter of nonreviewability related to those beds was issued by the Department of Health prior to July 1, 1993.

(v) The Department will not make a separate APR-DRG payment for inpatient acute care general hospital services of a normal newborn.