§ 1187.101. General payment policy.
(a) Payment for nursing facility services will be subject to the following conditions and limitations:
(1) This chapter and Chapter 1101 (relating to general provisions).
(2) Applicable State statutes.
(3) Applicable Federal statutes and regulations and the Commonwealth’s approved State Plan.
(b) Payment will not be made for nursing facility services at the MA per diem rate if full payment is available from another public agency, another insurance or health program or the resident’s resources.
(c) Payment will not be made in whole or in part for nursing facility services provided during a period in which the nursing facility’s participation in the MA Program is terminated.
(d) Claims submitted for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101. In addition, the Department will perform the reviews specified in this chapter for controlling the utilization of nursing facility services.
Cross References This section cited in 55 Pa. Code § 1187.21 (relating to nursing facility participation requirements).
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