Section 51.44. Payment policies

(a) The Department will only pay for HCBS in accordance with this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies).

(b) When a provision specified in Chapter 1101 or 1150 is inconsistent with this chapter, this chapter is applicable.

(c) The Department will only pay for compensable HCBS up to the amount, duration and frequency as listed on the participant’s ISP as approved by the Department or the Department’s designee and rendered by the provider.

(d) If an HCBS is allowable under a third-party medical resource, the provider shall bill the third-party medical resource in accordance with § 1101.64 (relating to third-party medical resources (TPR)) before billing a Federal or State-funded program.

(e) If the HCBS is billable under the MA State Plan, a provider shall bill the program under the MA State Plan before billing the HCBS waiver or State-funded programs.

(f) The provider shall retain documentation of the third-party medical resource denial and billing attempts and submissions for an HCBS under the MA State Plan or a third-party medical resource agency for at least 5 years from the provider’s State fiscal year-end.

(g) Payments made to a provider under the MA Program constitute payment in full to the provider.

(h) A provider who receives a supplemental payment other than room and board from the Department, the participant or another person for an HCBS shall return the supplemental payment to the payer.

(i) A provider shall comply with § § 1101.63 and 1101.68 (relating to payment in full; and invoicing for services).

(j) The Department will only pay for HCBS in accordance with the approved applicable waiver and this chapter.

(k) The Department will recoup payments which are not made in accordance with this section.