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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 § 1126.51. General payment policy.


§ 1126.51. General payment policy.

 (a)  Payment is made for support services related to procedures provided by participating ASCs and SPUs. Payment is subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and medical assistance program payment policies).

 (b)  A fee determined by the Department is paid to an ASC or an SPU for support services relating to a covered procedure provided to an eligible recipient at the facility.

 (c)  The ASC or SPU is considered the provider regardless of whether the facility is operated directly by the enrolled provider or through contract between the provider and other organizations or individuals. The enrolled provider is responsible for the delivery of service and for billings.

 (d)  When two or more compensable procedures are performed during the same ASC or SPU stay, the services relating to the procedure carrying the highest payment shall be paid in full with no allowance for additional procedures.

 (e)  The fee paid to the facility shall include but is not limited to:

   (1)  Nursing, technician and related services.

   (2)  Use of the facility.

   (3)  Drugs, biologicals, surgical dressings, supplies, splints, casts and appliances and equipment directly related to the provision of surgical procedures.

   (4)  Administrative, recordkeeping and housekeeping items and services.

   (5)  Materials for anesthesia.

 (f)  The ASC or SPU shall submit invoices to the Department in accordance with the instructions in the Provider Handbook.

 (g)  If an ASC or SPU has a fee schedule based on the patient’s ability to pay, the Department will consider the provider’s usual and customary charge to the general public to be the most frequent charge to the self-paying public for the same service in the preceding calendar month.

 (h)  The Department will pay the lesser of the facility’s charge to the general public or the amount determined as the fee that the facility is eligible to bill.

 (i)  Payment will be retroactively denied for sterilizations found to be out of compliance with §  1126.55 (relating to payment conditions for sterilizations) and for abortions found to be out of compliance with §  1141.57 (relating to payment conditions for necessary abortions).

 (j)  Payment will be made for services provided to Commonwealth Medical Assistance recipients by an out-of-State ASC or hospital SPU only if residents in a given area generally receive their care in that particular facility. This will apply when the out-of-State facility is closer to, or substantially more accessible from, the residence of the recipient than the nearest facility within this Commonwealth that is adequately equipped to deal with, and is available for the treatment of, the individual’s illness or injury.

 (k)  Payment will be made to ASC/SPU facilities for services provided to patients who, in conjunction with a same day service, are transferred to a hospital due to complications.

 (l)  Payment will be made under Chapter 1163 (relating to inpatient hospital services) for care provided to patients who, due to complications, must be transferred to inpatient hospital care.

 (m)  Compensable diagnostic medical services, including preadmission testing, electrocardiograms and diagnostic or therapeutic radiology services provided in conjunction with same day surgical services are compensable to the hospital or the ASC in addition to the payment for support services if the facility is otherwise eligible to provide the services, and if the services are provided prior to the day of admission. Diagnostic services provided on the day of admission are considered ancillary services and are included under the support component paid to facilities for a procedure.

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