Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 488 (January 27, 2024).

55 Pa. Code § 1101.64. Third-party medical resources (TPR).

§ 1101.64. Third-party medical resources (TPR).

 (a)  General. Other private or governmental health insurance benefits shall be utilized before billing the MA Program. Providers shall make reasonable efforts to secure from the recipient sufficient information regarding the primary coverages necessary to bill the insurers or programs. The medical resources which are primary third parties to MA include Medicare; CHAMPUS (Civilian Health and Medical Programs of the Uniformed Services); Blue Cross, Blue Shield or other commercial insurance; VA benefits; Workman’s Compensation; and the like. The information needed to bill third parties includes the insurer’s name and address, policy or group I.D. number, and the patient’s or the patient’s employer’s address. When the total amount of payment by the third-party resource is less than the Department’s fee or rate for the same service, the provider may bill the Department for the difference by submitting an invoice with a copy of the third party’s statement of payments attached. If a third-party resource refuses payment to the provider based on coverage exclusions or other reasons, the provider may bill the Department by submitting an invoice with a copy of the third party’s refusal advisory attached.

 (b)  Persons covered by Medicare and MA. If a MA recipient also has Medicare coverage, the Department may be billed for charges that Medicare applied to the deductible or coinsurance, or both. Payment will be made in accordance with established MA rates and fees.

Cross References

   This section cited in 55 Pa. Code §  1101.33 (relating to recipient eligibility); 55 Pa. Code §  1140.54 (relating to noncompensable services and items); 55 Pa. Code §  1142.55 (relating to noncompensable services); 55 Pa. Code §  1144.53 (relating to noncompensable services); 55 Pa. Code §  1155.31 (relating to general payment policy); 55 Pa. Code §  1187.155 (relating to exceptional DME grants—payment conditions and limitations); and 55 Pa. Code §  6100.482 (relating to payment).

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