Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 7346 (November 25, 2023).

55 Pa. Code § 6100.482. Payment.

§ 6100.482. Payment.

 (a)  The Department will only pay for an HCBS in accordance with this chapter and Chapter 1101 (relating to general provisions).

 (b)  When a provision in Chapter 1101 is inconsistent with this chapter, this chapter applies.

 (c)  The Department will only pay for a reimbursable HCBS up to the maximum amount, duration and frequency as specified in the approved and documented individual plan and as delivered by the provider.

 (d)  If an HCBS is payable under a third-party medical resource, the provider shall bill the third-party medical resource in accordance with §  1101.64 (relating to third-party medical resources (TPR)) before billing a Federal or State-funded program.

 (e)  If the HCBS is eligible for payment under the State plan, the provider shall bill the program under the State plan before billing the HCBS waiver or State-funded programs.

 (f)  The provider shall document a third-party medical resource claim submission and denial for an HCBS under the State plan or a third-party medical resource agency.

 (g)  Medical Assistance payment, once accepted by the provider, constitutes payment in full.

 (h)  A provider who receives a supplemental payment for a service that is included as a service in the individual plan, or that is eligible for payment as an HCBS, shall return the supplemental payment to the payer. If the payment is for an activity that is beyond the services specified in the individual plan or for an activity that is not eligible as an HCBS, the private payment from the individual or another person is permitted.

Cross References

   This section cited in 55 Pa. Code §  6100.805 (relating to vendor goods and services).

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