§ 1163.455. Noncompensable services and items.
(a) The Department will not pay hospitals for inpatient services directly or indirectly related to or in conjunction with:
(1) Inpatient hospital services provided in conjunction with physicians’ services which are identified as outpatient procedures in Chapter 1150 (relating to MA Program payment policies) and the MA Program Fee Schedule unless the procedure is performed as a secondary necessary procedure.
(2) Diagnostic tests and procedures that can be performed on an outpatient basis and diagnostic tests and procedures not related to the diagnoses that require that particular inpatient stay.
(3) Services and items for which full payment is available through Medicare, other financial resources or other health insurance programs.
(4) Services and items not ordinarily provided to the general public.
(5) Periods of absence from the hospital for a purpose such as employment or school attendance except for therapeutic leaves that enable individuals to attend family matters of significant importance. The number of therapeutic leaves during one period of hospitalization is limited under § 1163.454(c) (relating to limitations on payment).
(6) Diagnostic or therapeutic procedures solely for experimental, research or educational purposes.
(7) Unnecessary admissions and conditions which do not require hospital-type care, such as rest cures and room and board for relatives during a patient’s hospitalization.
(8) Inpatient services provided to patients who no longer require acute short-term inpatient hospital care—inappropriate hospital services. For patients who do require skilled nursing or intermediate care, payment will be made to the hospital under Chapter 1181 (relating to nursing facility care) or successor provisions for this care only if the patient is in a certified and approved hospital-based skilled nursing or intermediate care unit.
(9) Inpatient hospital days not certified under the Department’s Concurrent Hospital Review (CHR) process or, if the hospital is granted an exemption from CHR, not certified by the hospital’s in-house utilization review process. If an MA patient refuses to leave after being discharged by the attending practitioner when the approved length of stay is exhausted, the hospital may bill the patient.
(10) Days of inpatient care due to unnecessary delay in applying for a court-ordered commitment, grace periods, administrative days and custodial care related or unrelated to court commitments or to the child protective services. For purposes of this chapter, custodial care is defined as maintenance, rather than curative care, on an indefinite basis. Grace periods and administrative days relate to days of care while awaiting placement elsewhere.
(11) Inpatient hospital services provided to a recipient by the transferring hospital on or after the effective date of a court commitment to another facility.
(12) Days of inpatient hospitalization due to the failure to promptly request or perform necessary diagnostic studies, medical-surgical procedures or consultations.
(13) Friday or Saturday admissions unless one of the following occurs:
(i) The admission is an emergency as documented in the patient’s medical record by the admitting physician.
(ii) The medical or surgical procedure for which the patient was admitted is performed on the day of or the day following admission.
(14) The day of discharge from inpatient hospital care except for same calendar day admissions and discharges.
(15) A day of inpatient hospital care provided to a recipient whose medical condition makes the person suitable for an alternate level of care.
(16) Drug or alcohol, or both, detoxification and rehabilitation or rehabilitation services in an inpatient facility unless one of the following circumstances exists:
(i) Complications exist, or there is a reasonable expectation of complications, that require inpatient facility medical treatment, including:
(A) An individual requires acute inpatient treatment based on the presence of a major medical complication or a significant psychiatric problem, or an individual has a history of significant substance abuse and a complication as described in § 1163.59(d)(1)(i), (ii), (iii) or (iv) (relating to noncompensable services, items and outlier days).
(B) An individual in residential care exhibits significant medical or psychiatric complications as described in § 1163.59(d)(1)(i), (ii), (iii) or (iv), and requires more intensive treatment and observation.
(ii) Detoxification has been certified by the Department and completed in an acute care general hospital, and the patient is discharged directly from the acute care general hospital where the detoxification occurred to the inpatient hospital rehabilitation setting.
(iii) A nonhospital, medically appropriate bed is not available within a 50-mile radius of the inpatient hospital to which the patient presents for drug or alcohol detoxification or rehabilitation services and the inpatient hospital rehabilitation facility includes documentation of the nonavailability of the nonhospital bed in the medical record. A nonhospital bed will be considered to be not available if the medically appropriate nonhospital facility has no beds available or refuses to accept the patient.
(b) The Department will not pay hospitals for services or items listed in subsection (a) even if the attending physician or hospital utilization review committee determines that the stay was medically necessary.
(c) The Department will not pay hospitals on a cost related basis for services or items covered under this subchapter even if the attending physician or hospital utilization review committee determines that the services or items were medically necessary.
Authority The provisions of this § 1163.455 amended under sections 201(2) and 443.1(1) of the Public Welfare Code (62 P. S. § § 201(2) and 443.1(1)).
Source The provisions of this § 1163.455 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended through October 10, 1986, effective retroactively to July 1, 1984, 16 Pa.B. 3828; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective July 1, 1993, 23 Pa.B. 5241; amended November 3, 1995, effective November 4, 1995, and apply retroactively to October 1, 1995, 25 Pa. B. 4700; amended November 24, 1995, effective November 25, 1995, and apply retroactively to November 1, 1995, 25 Pa. B. 5241. Immediately preceding text appears at serial pages (181878) to (181880).
Cross References This section cited in 55 Pa. Code § 1163.451 (relating to general payment policy); 55 Pa. Code § 1163.453 (relating to allowable and nonallowable costs); 55 Pa. Code § 1163.457 (relating to payment policies relating to out-of-State hospitals); and 55 Pa. Code § 1163.475 (relating to responsibilities of the hospital utilization review committee).
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