Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 8238 (December 30, 2023).

55 Pa. Code § 1151.49. Third-party liability.

§ 1151.49. Third-party liability.

 (a)  Inpatient psychiatric facilities shall utilize the available third-party resources for services a recipient receives while in the inpatient psychiatric facility.

 (b)  If expected payment by a third-party resource is not realized, the inpatient psychiatric facility may bill the MA Program.

 (c)  If the psychiatric facility receives reimbursement from a third-party subsequent to payment from the Department, the facility shall repay the Department by submitting a claim adjustment.

 (d)  If a recipient or the legal representative of a recipient requests a copy of the facility’s invoice, the facility shall submit a copy of the invoice and the request to the Department’s Office of Administration at the address specified in the Provider Handbook. The Office of Administration will forward the requested copy to the requestor and take follow-up action necessary to ensure the repayment of MA expenditures.

 (e)  If a recipient is entitled to Medicare Part A benefits, the Department will pay the amount of the Medicare deductible and coinsurance minus other resources available to the recipient for the psychiatric inpatient care.

 (f)  Except as specified in subsection (g), if a recipient is entitled to hospital insurance benefits other than Medicare Part A, the Department will pay the lesser of the following:

   (1)  The inpatient psychiatric facility’s per diem rate multiplied by the number of compensable inpatient psychiatric days of care rendered, minus resources available to the recipient for hospital care, including Medicare Part B payments.

   (2)  The amount of the insurance plan’s deductible and coinsurance minus other resources available to the recipient for inpatient psychiatric care, including Medicare Part B payments.

 (g)  If the resources available to a recipient for inpatient psychiatric care equal or exceed the inpatient psychiatric facility’s per diem rate multiplied by the number of compensable inpatient psychiatric days of care rendered, the Department will make no payment for the inpatient psychiatric facility care.

 (h)  The inpatient psychiatric facility shall utilize resources available through Medicare Part B for services provided in the facility that are covered and approved for payment by Medicare.

Authority

   The provisions of this §  1151.49 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. § §  201 and 443.1(1)).

Source

   The provisions of this §  1151.49 adopted September 30, 1983, effective July 1, 1983, 13 Pa.B. 2796; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective July 1, 1993, 23 Pa.B. 5241. Immediately preceding text appears at serial pages (181786) to (181787).



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