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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 § 1151.41. General payment policy.


§ 1151.41. General payment policy.

 (a)  This chapter and Chapter 1101 (relating to general provisions) govern payment for inpatient psychiatric facility services.

 (b)  If a recipient is readmitted to an inpatient psychiatric facility within 24 hours of the recipient’s discharge from the same facility, it will not be considered a new admission for MA purposes, but rather a continuation of the original admission.

 (c)  If a recipient is admitted to an inpatient psychiatric facility and discharged the same calendar day, the Department will do the following:

   (1)  Pay one-half of the per diem rate determined by the Department for the facility under §  1151.46 (relating to payment rate calculations for Fiscal Years 1993-94 and 1994-95).

   (2)  Count the stay as one-half of an inpatient day for cost settlement purposes, for facilities which are subject to cost settlement.

 (d)  Payment for preadmission laboratory tests, radiology services and other diagnostic services provided to patients admitted to an inpatient psychiatric facility will be included in the payment for inpatient services. If preadmission diagnostic services are provided to a patient who is scheduled to be admitted but who is not admitted to the inpatient psychiatric facility as expected, the diagnostic services shall be billed as outpatient services according to Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule.

 (e)  An inpatient psychiatric facility may not seek reimbursement from an MA recipient if either the facility’s utilization review committee or the Department, through its Concurrent Hospital Review process, denies certification for that recipient’s days of care. If a patient who has been discharged by a physician refuses to leave the facility at the end of a certified stay, the facility may bill the recipient for days used beyond the length of stay certified by the Department or the facility’s utilization review committee.

 (f)  The inpatient psychiatric facility may bill an MA recipient for days of care related to a noncovered service if the recipient was informed prior to receiving the service that the particular service and the inpatient care relating to the service were not covered under the MA Program.

 (g)  The inpatient psychiatric facility may not bill the MA Program for services provided to a person who has applied for MA benefits unless the CAO has notified the MA facility that the person is eligible for MA benefits.

 (h)  If a private psychiatric hospital, or the general hospital of which the psychiatric unit is a part, voluntarily terminates the provider agreement, payment for inpatient services continues for MA patients admitted prior to the date on which the facility announced its intent to withdraw from the program, until the effective date of the termination. The Department will not pay for services provided on or after the effective date of the termination of the provider agreement.

 (i)  The Department will continue to make payment to a facility affected by a strike for patients temporarily transferred to a facility licensed to provide the required care. If the facility to which the patient is transferred has a per diem rate which is different from that of the transferring facility, the transferring facility will be reimbursed the lower rate. The facility shall immediately notify the Office of Medical Assistance Programs in writing of an impending strike and follow with a listing of MA patients and the facility to which they are to be transferred.

 (j)  For payment to be made for laboratory tests and other diagnostic procedures, the studies shall be related to the patient’s condition and be specifically ordered in writing for the particular patient by the attending physician or other licensed practitioner who is responsible for determining the diagnosis or treatment of that patient. In emergency situations, an exception will be made to the requirement that studies be specifically ordered in writing if the test or procedure is necessary to prevent the death or serious impairment of the health of the recipient. Payment will not be made for diagnostic services performed pursuant to a preprinted regimen.

 (k)  As part of the discharge planning process, the inpatient psychiatric facility shall refer the patient to the local mental health program in the patient’s county of residence.


   The provisions of this §  1151.41 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. § §  201 and 443.1(1)).


   The provisions of this §  1151.41 adopted September 30, 1983, effective July 1, 1983, 13 Pa.B. 2976; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective October 30, 1993, 23 Pa.B. 5241. Immediately preceding text appears at serial pages (181775) to (181777).

Cross References

   This section cited in 55 Pa. Code §  1151.41a (relating to clarification of the term ‘‘in writing’’—statement of policy).

Notes of Decisions

   Petitioner, who was denied medical assistance certification for days of care, did not suffer a pecuniary interest from the Department’s denial of payment to a provider and lacked standing to challenge the Department’s order as the provider could not seek reimbursement from a medical assistance recipient if certification for days of care is denied. Campion v. Department of Public Welfare, 545 A.2d 491 (Pa. Cmwlth. 1988).

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