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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 6142 (September 30, 2023).

55 Pa. Code § 1126.41. Participation requirements.


§ 1126.41. Participation requirements.

 (a)  In addition to the participation requirements established in Chapter 1101 (relating to general provisions), an independently operated ASC or hospital SPU shall:

   (1)  Be enrolled in the MA Program as an ASC or a hospital SPU.

   (2)  Abide by applicable Federal and State statutes and regulations, including, but not limited to, Title XIX of the Social Security Act (42 U.S.C.A. § §  1396—1396p), the Public Welfare Code (62 P. S. § §  101—1503) and applicable licensing statutes.

   (3)  Have an established schedule of charges for billing third parties and private payors that is published and made available to the general public.

   (4)  If requested, furnish information to the Department necessary to establish rates as specified in §  1126.53 (relating to limitations on covered procedures), in the form and manner the Department requires.

 (b)  In addition to the participation requirements set forth in subsection (a), a hospital SPU shall:

   (1)  Be enrolled as a provider of ambulatory surgical services separately from, and in addition to, the hospital’s enrollment with the Department as a provider of inpatient services.

   (2)  Be part of an institution that is licensed as a hospital by the Department of Health and meets the requirements for participation in Medicare. An SPU meeting those qualifications is eligible to participate and be compensated as a provider of same day surgical services.

   (3)  Submit to the Department information regarding the bed complement and location of the distinct part ambulatory surgical unit.

 (c)  In addition to the participation requirements set forth in subsection (a), an ASC shall be certified as meeting the Medicare requirements at 42 CFR 416 (relating to ambulatory surgical services).

 (d)  If abortions are performed in an ASC, the facility shall be licensed/approved by the Department of Health to provide this service.

 (e)  Out-of-State ASCs and SPUs providing services to Commonwealth recipients shall, in addition to complying with the appropriate requirements of this section, either be Medicare certified or be approved by the appropriate agency of the state in which the ASC or SPU is located as meeting standards comparable to Medicare.

 (f)  The Department reserves the right to refuse to enter into a provider agreement with a licensed ASC or hospital SPU whenever it determines that it is in the Department’s best interests to do so.

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