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
PROVIDER PARTICIPATION
Section 1163.41 - General participation requirements

Universal Citation: 55 PA Code ยง 1163.41

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

(a) In addition to the participation requirements established in Chapter 1101 (relating to general provisions) general hospitals shall:

(1) Be licensed by the Department of Health.

(2) Have in effect a utilization review plan approved by Medicare or, for a hospital not participating in Medicare, a utilization review plan approved by the Office of MA. For a utilization review plan to be approved by the Office of MA, it shall comply with § 1163.73 (relating to the hospital utilization review plan).

(b) Out-of-State hospitals furnishing inpatient hospital care to Commonwealth recipients shall:

(1) Be Medicare certified, or certified by the appropriate agency of the state in which the hospital is located as meeting standards comparable to Medicare or be certified by either the Joint Committee on Accreditation of Hospitals (JCAH) or the American Osteopathic Association (AOA).

(2) Be currently participating in the Medicaid Program of the state in which the hospital is located.

(3) Formally enroll in the MA Program and sign a provider agreement if in a contiguous state or if more than three invoices are submitted for payment within a 12-month period. If an out-of-State hospital not in a contiguous state submits less than three invoices within a 12-month period, the Department will process the invoices without requiring the hospital to formally enroll in the MA Program.

(c) The Department reserves the right to refuse to enter into a provider agreement with a licensed hospital or a distinct part thereof if it determines that it is in the Department's best interest to do so.

The provisions of this §1163.41 amended under sections 201 and 443.1(1) and (4) of the Public Welfare Code (62 P. S. §§ 201 and 443.1(1) and (4)).

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