§ 69.3. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Act 6—The act of February 7, 1990 (P. L. 11, No. 6).
Burn facility—A facility which meets the service standards of the American Burn Association.
Care or services—The treatment, accommodations, products or services provided by a person or institution.
Carrier—An organization with a contractual relationship with HCFA to process Medicare Part B claims.
Commissioner—The Insurance Commissioner of the Commonwealth.
DRG—Diagnostic-related group.
Department—The Insurance Department of the Commonwealth.
HCFA—The Health Care Financing Administration.
Insured—An injured person covered by an automobile insurance policy issued under the MVFRL.
Insurer—A property and casualty insurance company providing coverage under automobile insurance policies to residents of this Commonwealth.
Intermediary—An organization with a contractual relationship with HCFA to process Medicare Part A claims.
Life-threatening injury—The term shall be as defined by the American College of Surgeons’ triage guidelines regarding the use of trauma centers for the region where the services are provided.
MVFRL—Motor Vehicle Financial Responsibility Law—Title 75 of the Pennsylvania Consolidated Statutes § § 1701—1799.7 (relating to the Motor Vehicle Financial Responsibility Law).
Medicare Part A—Medicare hospital insurance benefits which reimburse providers for facility-based care, such as in-patient and out-patient hospital services and skilled nursing care.
Medicare Part B—Medicare supplementary medical insurance which reimburses providers for physician services, durable medical equipment, physical therapy and other services.
Medicare payment—Payment at 110% of the Medicare reimbursement allowance which includes the prevailing charge at the 75th percentile; the applicable fee schedule, the recommended fee or the inflation index charge; the DRG payment; or any other Medicare reimbursement mechanism; as applied in this Commonwealth under the Medicare Program.
Medicare prevailing charge—The lowest customary charge high enough to include 75% of the individual provider charges for services as adjusted by all limitations mandated by HCFA and the carrier.
Medicare recommended fee—The fee for which a Medicare payment schedule does not exist, and which is developed based upon a solicited recommendation from a consulting specialist or group of specialists. This fee may vary depending upon the specifics of a particular case.
PRO—Peer Review Organization—A professional organization with which HCFA or the Commonwealth contracts for medical review of Medicare or Medical Assistance services, or a health care entity approved by the Commissioner, that engages in reviewing medical files for the purpose of determining that medical and rehabilitation services are medically necessary and economically provided.
Pass-through costs—Medicare reimbursed costs to a hospital that ‘‘pass through’’ the prospective payment system and are not included in the DRG payments. The term includes medical education, capital expenditures, insurance and interest expense on fixed assets.
Provider—A person or institution which provides treatment, accommodations, products or services.
Trauma center—A facility accredited by the Pennsylvania Trauma Systems Foundation under the Emergency Medical Services Act (35 P. S. § § 6921—6938).
Urgent injury—The term shall be as defined by the American College of Surgeons’ triage guidelines regarding use of trauma centers for the region where the services are provided.
Usual and customary charge—The charge most often made by providers of similar training, experience and licensure for a specific treatment, accommodation, product or service in the geographic area where the treatment, accommodation, product or service is provided.
Notes of Decisions Usual and Customary Charge
The definition of ‘‘usual and customary charge’’ establishes the reimbursement level for the single provider based on an aggregate of charges for similarly situated providers and is not inconsistent with 75 Pa.C.S. § 1797. Hospital Association of Pennsylvania, Inc. v. Foster, 629 A.2d 1055 (Pa. Cmwlth. 1993).
The definition of ‘‘usual and customary charge’’ does not conflict with the meaning of the legislature’s language and the common usage of 2 terms under the Medicare Program. Hospital Association of Pennsylvania, Inc. v. Foster, 629 A.2d 1055 (Pa. Cmwlth. 1993).
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