§ 1151.48. Noncompensable services and items.
(a) The Department will not pay an inpatient psychiatric facility for:
(1) Experimental procedures and services that are not in accordance with customary standards of medical practice or that are not commonly used.
(2) A day of inpatient care solely for the purpose of performing diagnostic tests that can be performed on an outpatient basis, or tests not related to the diagnoses that require the inpatient hospital care.
(3) A day of inpatient care if payment is available from another public agency or another insurance or health program.
(4) Services not ordinarily provided to the general public.
(5) Methadone maintenance.
(6) Days of care during which the patient was absent from the inpatient psychiatric facility to attend school, conferences or meetings, to participate in other activities outside the facility, or for employment except for therapeutic leave under § 1151.43 (relating to limitations on payment).
(7) Custodial care related or unrelated to court commitments. Payment for services provided to recipients confined to an inpatient psychiatric facility under a court commitment for any reason will be made only if medical necessity exists for psychiatric inpatient care.
(8) Diagnostic or therapeutic procedures for experimental research or educational purposes.
(9) Unnecessary admissions and days of care due to conditions which do not require psychiatric inpatient care, such as, rest cures and room and board for relatives during a recipient’s hospitalization.
(10) Days of care for recipients who no longer require psychiatric inpatient care. The Department does make payment to an inpatient psychiatric facility for skilled nursing or intermediate care provided for a recipient in a certified bed in a certified and approved hospital-based skilled nursing or intermediate care unit in accordance with Chapter 1181 (relating to nursing facility care) or successor provisions.
(11) Days of care for recipients remaining in an inpatient psychiatric facility beyond the length of stay certified by the Department’s Concurrent Hospital Review (CHR) unit, or, if the hospital has been granted an exemption to the CHR process, days of care beyond the length of stay certified by the hospital’s utilization review committee.
(12) Grace periods, such as pending discharge of a recipient when inpatient hospital care is no longer needed.
(13) Days of care due to failure to promptly request or perform necessary diagnostic studies or consultations.
(14) Days of care on or after the effective date of a court commitment to another facility.
(15) Days of inpatient care provided to a recipient who is suitable for an alternate type or level of care, regardless of whether the recipient is under voluntary or involuntary commitment.
(16) Diagnostic procedures or laboratory tests not specifically ordered by the physician or practitioner responsible for the diagnosis or treatment of the patient unless the procedure or test is necessary to prevent the death or serious impairment of the patient’s health.
(17) Diagnostic procedures or laboratory tests ordered by means of a stamped or preprinted regimen.
(18) The day of discharge unless it is also the day of admission.
(19) Days of care not certified in accordance with the Department’s concurrent hospital review process unless the inpatient psychiatric facility has been granted an exemption by the Department.
(20) Days of care due to failure to promptly apply for a court-ordered commitment.
(b) The Department will not pay inpatient psychiatric facilities for services or items provided in conjunction with the provision of a service or item in subsection (a).
(c) The Department will not pay inpatient psychiatric facilities for services or items in subsection (a) even if the attending physician or hospital utilization review committee determines that the stay was medically necessary.
Authority The provisions of this § 1151.48 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 § 1151.48 adopted September 30, 1983, effective July 1, 1983, 13 Pa.B. 2796; amended November 18, 1983, effective November 19, 1983, 13 Pa.B. 3665; 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 (181784) to (181786).
Notes of Decisions Unnecessary Admissions
The Department’s determination that patient’s admission was unnecessary was erroneous where the patient was admitted pursuant to a court commitment order. That order constituted a legal determination that commitment in the appellant’s facility was appropriate and necessary. Devereux Hospital Texas Treatment Network v. Department of Public Welfare, 797 A.2d 1037 (Pa. Cmwlth. 2002); appeal granted 827 A.2d 1202 (Pa. 2003); affirmed in part; reversed in part 855 A.2d 842 (Pa. 2004); remand 878 A.2d 967 (Pa. Cmwlth. 2005); appeal denied 918 A.2d 748 (Pa. 2007).
Cross References This section cited in 55 Pa. Code § 1151.45 (relating to nonallowable costs); and 55 Pa. Code § 1151.74 (relating to responsibilities of the inpatient psychiatric facility utilization review committee).
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