Section 52.42. Payment policies

(a) Services will be paid as either a fee schedule service under § 52.45 (relating to fee schedule rates) or as a vendor good or service payment under § 52.51 (relating to vendor good or service payment).

(b) The Department will publish services specific to each waiver and the Act 150 program as a notice in the Pennsylvania Bulletin.

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

(d) The Department will only pay for a service in the type, scope, amount, duration and frequency as specified on the participant’s service plan as approved by the Department.

(e) A provider who accepts supplementary payment for an Act 150 service from a source other than the Department shall return the Act 150 payment to the Department. If the supplementary payment pays only a portion of the cost of the Act 150 service, the provider shall return an amount equal to the supplementary payment to the Department. This subsection does not apply to copayments.

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

(g) The Department may limit the type of service available in accordance with Federal and State laws, the waiver program requirements or Act 150 program requirements.

(h) The Department will not reimburse a provider who renders a service to a participant who does not have an approved service plan for the date when the service was rendered.

(i) To be paid the MA Program fee schedule rate or receive reimbursement for a vendor good or service, a provider shall comply with this chapter.

(j) The Department will not pay for a service which is rendered to a participant who is enrolled in a waiver or the Act 150 program that does not include the service.