Billing, Claims, and Payment Conditions
Requires accurate billing to every payer, sets out the Pennsylvania Medical Assistance payment conditions for home health services (orders and plan of treatment, certification, oral order countersignature, 60-day review, prior authorization, aide supervision documentation), the Medicare conditions for a certified agency, and how billing errors and overpayments are found, corrected and repaid.
About this policy
- Policy number
- PA-HH-BUS-02
- Version
- 1.0
- Main rule
- 55 Pa. Code §1249.52
- Library
- Pennsylvania home health · 56 policies
- Category
- Business
- Sections
- 17
In short
- We bill only for visits that were ordered, actually made, and documented the same day.
- Write your visit note the day of the visit and sign and date it; we never bill from a schedule.
- Medical Assistance visits also need prior authorization and a signed 60-day plan review.
- If you think a bill or note is wrong, tell the Administrator; we fix it and return any overpayment.
What's inside
17 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (55 Pa. Code §1249.52)
- 5. Medical Assistance Payment Conditions
- 6. Medicare Conditions (If Medicare-Certified)
- 7. Pre-Billing Review
- 8. Patient Charges
- 9. Errors and Overpayments
- 10. Responsibilities
- 11. Records and Compliance Monitoring
- 12. Staff Training
- 13. References
- 14. Related Policies and Forms
- 15. Approval
- 16. Revision History
An inspector may ask
- Walk me through how a visit becomes a claim. Who checks that the orders and plan are signed before you bill?
- For this Medical Assistance patient, show me the prior authorization and the signed 60-day plan review.
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