Pennsylvania Code
Title 55 - HUMAN SERVICES
Part VIII - Intellectual Disability and Autism Manual
Subpart C - Administration and Fiscal Management
Chapter 6100 - SERVICES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR AUTISM
GENERAL PAYMENT PROVISIONS
Section 6100.482 - Payment

(a) The Department will only pay for an HCBS in accordance with this chapter and Chapter 1101 (relating to general provisions).

(b) When a provision in Chapter 1101 is inconsistent with this chapter, this chapter applies.

(c) The Department will only pay for a reimbursable HCBS up to the maximum amount, duration and frequency as specified in the approved and documented individual plan and as delivered by the provider.

(d) If an HCBS is payable under a third-party medical resource, the provider shall bill the third-party medical resource in accordance with § 1101.64 (relating to third-party medical resources (TPR)) before billing a Federal or State-funded program.

(e) If the HCBS is eligible for payment under the State plan, the provider shall bill the program under the State plan before billing the HCBS waiver or State-funded programs.

(f) The provider shall document a third-party medical resource claim submission and denial for an HCBS under the State plan or a third-party medical resource agency.

(g) Medical Assistance payment, once accepted by the provider, constitutes payment in full.

(h) A provider who receives a supplemental payment for a service that is included as a service in the individual plan, or that is eligible for payment as an HCBS, shall return the supplemental payment to the payer. If the payment is for an activity that is beyond the services specified in the individual plan or for an activity that is not eligible as an HCBS, the private payment from the individual or another person is permitted.