Prudent Payment of Claims Suspended until April 2022

ODP Announcement 21-031 is to announce the continued suspension of Prudent Payment of claims for Medical Assistance providers through March 31, 2022. The Governor’s Budget Office has announced it will continue the temporary suspension of Prudent Payment of claims for Medical Assistance providers through March 31, 2022. Prudent Pay will be reinstated beginning April 2022 using a phased–in approach. For more information about Prudent Pay during the COVID–19 pandemic, please visit the Department of Human Services.

This action continues allowing providers to be paid in the next financial cycle after the claim is approved for payment. Please note all claims must still meet all other billing requirements before payment.

The ODP Intermediate Care Facilities (ICF) Rate Setting unit would like to remind all ICF/ID Providers that there is a regulation that requires providers to bill monthly:

§1101.68. Invoicing for services.

(a) Invoices. When billing for MA services or items, a provider shall use the invoices specified by the Department or its agents, according to billing and other instructions contained in the provider handbooks.

(b) Time frame. MA providers shall submit invoices correctly and in accordance with established time frames. For purposes of this section, time frames referred to are indicated in calendar days.

• A provider shall submit original or initial invoices to be received by the Department within a maximum of 180 days after the date the services were rendered or compensable items provided. Nursing facility providers and ICF/MR providers shall submit original or initial claims to be received by the Department within 180 days of the last day of a billing period.

A billing period for nursing facility providers and ICF/MR providers covers the services provided to an eligible recipient during a calendar month and starts on the first day service is provided in that calendar month and ends on the last day service is provided in that calendar month.

Split billing constitutes a regulatory violation. It has become apparent that PROMISe does not edit that situation properly; however, providers are still required to follow the regulation. Discovery of such violations can be found by any of the organizations within the Commonwealth that audit/review ICF/ID claims or expenditures, and can have negative consequences. Questions may be directed here.