Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1163 - INPATIENT HOSPITAL SERVICES
Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES
PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES
Section 1163.455 - Noncompensable services and items
Universal Citation: 55 PA Code ยง 1163.455
Current through Register Vol. 54, No. 44, November 2, 2024
(a) The Department will not pay hospitals for inpatient services directly or indirectly related to or in conjunction with:
(1) Inpatient hospital services provided in
conjunction with physicians' services which are identified as outpatient
procedures in Chapter 1150 (relating to MA Program payment policies) and the MA
Program Fee Schedule unless the procedure is performed as a secondary necessary
procedure.
(2) Diagnostic tests and
procedures that can be performed on an outpatient basis and diagnostic tests
and procedures not related to the diagnoses that require that particular
inpatient stay.
(3) Services and
items for which full payment is available through Medicare, other financial
resources or other health insurance programs.
(4) Services and items not ordinarily
provided to the general public.
(5)
Periods of absence from the hospital for a purpose such as employment or school
attendance except for therapeutic leaves that enable individuals to attend
family matters of significant importance. The number of therapeutic leaves
during one period of hospitalization is limited under §
1163.454(c)
(relating to limitations on payment).
(6) Diagnostic or therapeutic procedures
solely for experimental, research or educational purposes.
(7) Unnecessary admissions and conditions
which do not require hospital-type care, such as rest cures and room and board
for relatives during a patient's hospitalization.
(8) Inpatient services provided to patients
who no longer require acute short-term inpatient hospital care-inappropriate
hospital services. For patients who do require skilled nursing or intermediate
care, payment will be made to the hospital under Chapter 1181 (relating to
nursing facility care) or successor provisions for this care only if the
patient is in a certified and approved hospital-based skilled nursing or
intermediate care unit.
(9)
Inpatient hospital days not certified under the Department's Concurrent
Hospital Review (CHR) process or, if the hospital is granted an exemption from
CHR, not certified by the hospital's in-house utilization review process. If an
MA patient refuses to leave after being discharged by the attending
practitioner when the approved length of stay is exhausted, the hospital may
bill the patient.
(10) Days of
inpatient care due to unnecessary delay in applying for a court-ordered
commitment, grace periods, administrative days and custodial care related or
unrelated to court commitments or to the child protective services. For
purposes of this chapter, custodial care is defined as maintenance, rather than
curative care, on an indefinite basis. Grace periods and administrative days
relate to days of care while awaiting placement elsewhere.
(11) Inpatient hospital services provided to
a recipient by the transferring hospital on or after the effective date of a
court commitment to another facility.
(12) Days of inpatient hospitalization due to
the failure to promptly request or perform necessary diagnostic studies,
medical-surgical procedures or consultations.
(13) Friday or Saturday admissions unless one
of the following occurs:
(i) The admission is
an emergency as documented in the patient's medical record by the admitting
physician.
(ii) The medical or
surgical procedure for which the patient was admitted is performed on the day
of or the day following admission.
(14) The day of discharge from inpatient
hospital care except for same calendar day admissions and discharges.
(15) A day of inpatient hospital care
provided to a recipient whose medical condition makes the person suitable for
an alternate level of care.
(16)
Drug or alcohol, or both, detoxification and rehabilitation or rehabilitation
services in an inpatient facility unless one of the following circumstances
exists:
(i) Complications exist, or there is a
reasonable expectation of complications, that require inpatient facility
medical treatment, including:
(A) An
individual requires acute inpatient treatment based on the presence of a major
medical complication or a significant psychiatric problem, or an individual has
a history of significant substance abuse and a complication as described in
§
1163.59(d)(1)(i), (ii), (iii) or
(iv) (relating to noncompensable services,
items and outlier days).
(B) An
individual in residential care exhibits significant medical or psychiatric
complications as described in §
1163.59(d)(1)(i), (ii), (iii) or
(iv), and requires more intensive treatment
and observation.
(ii)
Detoxification has been certified by the Department and completed in an acute
care general hospital, and the patient is discharged directly from the acute
care general hospital where the detoxification occurred to the inpatient
hospital rehabilitation setting.
(iii) A nonhospital, medically appropriate
bed is not available within a 50-mile radius of the inpatient hospital to which
the patient presents for drug or alcohol detoxification or rehabilitation
services and the inpatient hospital rehabilitation facility includes
documentation of the nonavailability of the nonhospital bed in the medical
record. A nonhospital bed will be considered to be not available if the
medically appropriate nonhospital facility has no beds available or refuses to
accept the patient.
(b) The Department will not pay hospitals for services or items listed in subsection (a) even if the attending physician or hospital utilization review committee determines that the stay was medically necessary.
(c) The Department will not pay hospitals on a cost related basis for services or items covered under this subchapter even if the attending physician or hospital utilization review committee determines that the services or items were medically necessary.
The provisions of this §1163.455 amended under sections 201(2) and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201(2) and 443.1(1)).
This section cited in 55 Pa. Code § 1163.451 (relating to general payment policy); 55 Pa. Code § 1163.453 (relating to allowable and nonallowable costs); 55 Pa. Code § 1163.457 (relating to payment policies relating to out-of-State hospitals); and 55 Pa. Code § 1163.475 (relating to responsibilities of the hospital utilization review committee).
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