Section 1101.33. Recipient eligibility

(a) Verification of eligibility. The County Assistance Office determines whether or not an applicant is eligible for MA services. If the applicant is determined to be eligible, the Department issues Medical Services Eligibility (MSE) cards that are effective from the first of the month through the last day of the month. Providers are responsible for checking the effective dates on the MSE card and for making sure that services are furnished to a person named on the card. The Department may not pay providers for services the provider rendered to persons ineligible on the date of service unless there is specific provision for the payment in the provider regulations. If the provider notes any discrepancies, he should call the recipient’s County Assistance Office to verify eligibility.

(b) Services restricted to a single provider. Providers are responsible for checking the recipient’s MSE card and other forms of notification sent to the provider by the Department, to verify that the recipient has not been restricted to obtaining the service from a single provider. The Department may not pay for a restricted service rendered by a provider other than the one to which a recipient has been restricted unless it was furnished in response to an emergency situation. Reference should be made to § 1101.91(b) (relating to recipient misutilization and abuse).

(c) Other resources. The MSE card lists any other medical coverage a recipient has of which the Department may be aware. However, the provider has the responsibility of attempting to identify and utilize all of the recipient’s medical resources before billing the Department as described in § 1101.64 (relating to third-party medical resources (TPR)).

The provisions of this § 1101.33 amended April 27, 1984, effective April 28, 1984, 14 Pa.B. 1454. Immediately preceding text appears at serial pages (86692) and (86693).

Notation

Notes of Decisions

It is the provider’s responsibility to fill out a newborn infant’s identification number. Nayak v. Department of Public Welfare, 529 A.2d 557 (Pa. Cmwlth. 1987).