§ 1163.66. Third-party liability.
(a) Hospitals shall utilize the available third-party resources for services a recipient receives while in the hospital. Medicare lifetime reserve days are considered available resources.
(b) If expected payment by a third party resource is not realized, the hospital may bill the MA Program.
(c) If the hospital receives reimbursement from a third-party subsequent to payment from the Department, the hospital 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 hospital invoice, the hospital shall submit a copy of the invoice and the request to the Bureau of Claim Settlement, MA Recovery Unit, at the address specified in the Provider Handbook. The Bureau of Claim Settlement will forward the requested copy to the requestor and take follow-up action necessary to ensure the repayment of MA expenditures.
(e) For a hospitalization with a discharge date on or after July 1, 2007, if a recipient is entitled to Medicare Part A benefits, the Department will not pay any deductible and coinsurance amounts if the Medicare payment exceeds the applicable DRG payment, including any outlier payments. If the Medicare payment is less than the applicable DRG payment including any outlier payments, the Department pays Medicare deductible and coinsurance amounts to the extent that the Department’s payment, the Medicare payment and any other resources available to the recipient for the hospital inpatient care combined do not exceed the applicable DRG payment, including any outlier payments. The Department will not pay more than the maximum deductible and coinsurance amounts.
(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 applicable DRG payment rate minus the insurer’s liability amount and other resources available to the recipient for hospital care, including any Medicare Part B payment.
(g) If the resources available to a recipient for inpatient hospital care equal or exceed the Department’s applicable DRG payment rate, the Department will make no payment for the hospital care.
(h) The hospital shall utilize resources available through Medicare Part B for those services provided in the hospital that are covered and approved for payment by Medicare.
Source The provisions of this § 1163.66 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended July 27, 2007, effective immediately and apply to inpatient hospital services with discharge dates on or after July 1, 2007, 37 Pa.B. 4065. Immediately preceding text appears at serial page (201308).
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