Policy Questions

Policy Questions

1. May I limit the number of Medical Assistance (MA) patients I accept in my practice?
Yes. Providers may limit the number of MA patients they serve provided that limitation is not based on a factor which violates a recipient's civil rights as defined in Section 1405(b) of the Public Welfare Code (62 P.S. Section 1405(b)) and program regulations (55 PA Code §1101.51(b)). This regulation mandates that providers are prohibited from denying services or otherwise discriminating against any MA recipient. Providers should display in a prominent area, such as waiting room, their policy on accepting MA payment for services.

2. If I am an enrolled MA provider, but I am currently not accepting MA patients, may I accept an MA patient as a private pay patient?
No. Enrolled providers may not agree to accept an MA patient as a private pay patient. If an enrolled provider is not accepting MA patients, the provider should refer a recipient who requests services to his or her local County Assistance Office (CAO).

3. May I bill an MA recipient for Medicare coinsurance if the payment from Medicare exceeds the MA fee and no additional payment will be made by MA?
No. MA regulations in Chapter 1101, section 1101.63, and Section 4714 of the Balanced Budget Act of 1997 mandate that enrolled providers accept, as payment in full, amounts paid by the Department of Human Services for services rendered to eligible recipients. If Medicare or other third-party resource payment is involved, and payment from the resource exceeds the current MA fee, this regulation is still applicable and the provider may not seek additional payment, including deductible and/or coinsurance amounts from the recipient.

4. How long must I keep file copies of MA claims, insurance denials, copies of Remittance Advices, etc.?
At least four years.

5. Is there a phone number to call for questions regarding policy issues?
The Provider Inquiry unit is available to provide both billing and policy-related informational support. Phone numbers for the Provider Inquiry toll-free lines can be found at Contact Information/Help for MA Providers.