2002); appeal denied 839 A.3d 354 (Pa. 2003). In addition to the record keeping and access requirements specified in this subsection, practitioners and purveyors in a shared health facility shall meet 1102.61 (relating to inspection by the Department). The failure of the administrative hearing officer to provide a full evidentiary, de novo hearing from a denial of an application for a Medical Assistance Provider Agreement constitutes reversible error. (vii)Services provided in an emergency situation as defined in 1101.21 (relating to definitions). REVISED JUDICATURE ACT OF 1961 Act 236 of 1961 AN ACT to revise and consolidate the statutes relating to the organization and jurisdiction of the courts of this state; the powers We make safe shipping arrangements for your convenience from Baton Rouge, Louisiana. This section cited in 55 Pa. Code 41.3 (relating to definitions); 55 Pa. Code 1101.69 (relating to overpaymentunderpayment); 55 Pa. Code 1101.69a (relating to establishment of a uniform period for the recoupment of overpayments from providers (COBRA)); 55 Pa. Code 1101.74 (relating to provider fraud); 55 Pa. Code 1127.81 (relating to provider misutilization); 55 Pa. Code 1150.59 (relating to PSR program); 55 Pa. Code 1181.68 (relating to upper limits of payment); 55 Pa. Code 1181.73 (relating to final reporting); 55 Pa. Code 1181.101 (relating to facilitys right to a hearing); 55 Pa. Code 1187.113b (relating to capital cost reimbursement waiversstatement of policy); 55 Pa. Code 1187.141 (relating to nursing facilitys right to appeal and to a hearing); 55 Pa. Code 1189.141 (relating to county nursing facilitys right to appeal and to a hearing); 55 Pa. Code 6210.122 (relating to additional appeal requirements); and 55 Pa. Code 6210.125 (relating to right to reopen audit). 522 (E. D. Pa. 1997), revd on other grounds, 171 F.3d 842 (3rd Cir. (ii)Granting the exception is a cost-effective alternative for the MA Program. 3653. This section cited in 55 Pa. Code 1143.51 (relating to general payment policy); and 55 Pa. Code 1143.58 (relating to noncompensable services and items). Pa. 1975); amended September 30, 1988, effective October 1, 1988, 18 Pa.B. (ii)For inpatient hospital services, provided in a general hospital, rehabilitation hospital or private psychiatric hospital, the copayment is $3 per covered day of inpatient care, to an amount not to exceed $21 per admission. Rite Aid of Pennsylvania, Inc. v. Houston, 171 F.3d 842 (3d Cir. (6)No exceptions will be granted for claims which were submitted for normal processing within normal deadlines and rejected by the Department due to provider error. Prepayment review is not prior authorization. (2)Committed a prohibited act as specified in this chapter or the appropriate separate chapter relating to each provider type or under Article XIV of the Public Welfare Code (62 P. S. 14011411). The MA Program does not reimburse recipients for their expenditures. (1)Medical facilities. (xix)Rental of durable medical equipment. 5240; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. Department of Public Welfare v. Soffer, 544 A.2d 1109 (Pa. Cmwlth. (c)The amount of restitution demanded by the Department will be the amount of the overpayment received by the ordering or prescribing provider or the amount of payments to other providers for excessive or unnecessary services prescribed or ordered. (2)The recipient would be risking his health if he waited for the service until he returned home. In addition to civil action or criminal prosecution and upon written notification by the Office of Medical Assistance or the Office of Claims Settlement, a recipient shall reimburse the Department for services, supplies and drugs that were improperly obtained, transferred to other persons, resold or exchanged for other merchandise or products. (v)A retrospective request for an exception must be submitted no later than 60 days from the date the Department rejects the claim because the service is over the benefit limit. 1986). (b)Services restricted to a single provider. (ix)Prescriptions for nursing facility staff. If the requested documentation is not received within 30 days from the date of the Departments request, a decision will be made based on available information. 1987). (5)Paragraphs (1)(4) do not apply if the provider is bankrupt or out-of-business and the debt is uncollectable under section 1903(d)(2)(D) of the Social Security Act (42 U.S.C.A. (iii)Practitioners share any of the following: common waiting areas, examining rooms, equipment, supporting staff or records. (c)Noncriminal penalties shall consist of the following: (1)A person who is convicted of a violation of subsection (a)(1), (2), (3), (4) or (5) shall, upon notification by the Department, forfeit all rights to MA benefits for any period of incarceration. Section 1402(a.1) requires that "every child of school age shall be provided with school nurse services" In the School Health regulations, 28 PA Code, Chapter 23, Section 23.74, it is a function of the school nurse to interpret the health needs of individual children. 1987). For the request to be considered, it should include statements from peer review bodies, probation officers where appropriate, or professional associates, giving factual evidence of why they believe the violations leading to the termination will not be repeated. (B)One medical rehabilitation hospital admission per fiscal year. 1990). (viii)Laboratory and X-ray services as specified in Chapter 1243 and Chapter 1230. (ix)The professional component of diagnostic radiology, nuclear medicine, radiation therapy and medical diagnostic services, when the professional component is billed separately from the technical component. (7)An appeal by the provider of the audit disallowance does not suspend the providers obligation to repay the amount of the overpayment to the Department. (c)Medically needy. Providers shall meet the reporting requirements specified in 1101.71(b) (relating to utilization control). (xx)Targeted case management services. (a)Supplementary payment for a compensable service. (x)Family planning services and supplies. A change in ownership or control interest of 5% or more shall be reported to the Department within 30 days of the date the change occurs. The provisions of this 1101.51 amended November 18, 1983, effective November 19, 1983, 13 Pa.B. 42 U.S.C. The provisions of this Ordinance are designed to achieve the following: 11.A. Disclosure shall include the identity of a person who has been convicted of a criminal offense under section 1407 of the Public Welfare Code (62 P. S. 1407) and the specific nature of the offense. A medical facility shall disclose to the Department, upon execution of a provider agreement or renewal thereof, the name and social security number of a person who has a direct or indirect ownership or control interest of 5% or more in the facility. (7)Submit a claim or refer a recipient to another provider by referral, order or prescription, for services, supplies or equipment which are not documented in the record in the prescribed manner and are of little or no benefit to the recipient, are below the accepted medical treatment standards, or are not medically necessary. Scope of division. The provisions of this 1101.62 amended November 18, 1983, effective November 19, 1983, 13 Pa.B. This section cited in 55 Pa. Code 1121.41 (relating to participation requirements); 55 Pa. Code 1123.41 (relating to participation requirements); 55 Pa. Code 1127.41 (relating to participation requirements); 55 Pa. Code 1128.41 (relating to participation requirements); 55 Pa. Code 1130.51 (relating to provider enrollment requirements); 55 Pa. Code 1130.52 (relating to ongoing responsibilities of hospice providers); 55 Pa. Code 1141.41 (relating to participation requirements); 55 Pa. Code 1142.41 (relating to participation requirements); 55 Pa. Code 1143.41 (relating to participation requirements); 55 Pa. Code 1144.41 (relating to participation requirements); 55 Pa. Code 1149.41 (relating to participation requirements); 55 Pa. Code 1187.22 (relating to ongoing responsibilities of nursing facilities); and 55 Pa. Code 1251.41 (relating to participation requirements). The provisions of this 1101.76 issued sections 403(a) and (b), 441.1 and 1410 under the act of June 13, 1967 (P. L. 31, No. (ii)For inpatient hospital services, provided in a general hospital, rehabilitation hospital or private psychiatric hospital, the copayment is $6 per covered day of inpatient care, not to exceed $42 per admission. (i)A provider is not paid for services or items rendered on and after the effective date of his termination from the program. No part of the information on this site may be reproduced forprofit or sold for profit. Search . (3)The Department will inform recipients subject to the limits established in this subsection and medical service providers of these limits and the recipients current usage of limited services. (3)The Department will issue a medicheck list containing the names of all providers who have been terminated from the Program. (2)Knowingly submit false information to obtain authorization to furnish services or items under MA. 1985). (e)For the purpose of subsection (d)(4)(ii)(iv) the Department will accept a volume discount as market value if it remains equal to or above the actual acquisition cost of the product. Reference should be made to 1101.91(b) (relating to recipient misutilization and abuse). 1993); appeal denied 634 A.2d 225 (Pa. 1993). The market value of a pharmacy consultants fee shall be at least the average hourly wage of a pharmacist in that particular geographic area. The provisions of this 1101.75a adopted October 1, 1993, effective October 2, 1993, 23 Pa.B. (xxii)Outpatient services when the MA fee is under $2. (4)Except for the exclusions specified in paragraphs (2) and (3), each MA service furnished by a provider to an eligible recipient is subject to copayment requirements. (3)In addition to the penalties specified in subsections (a) and (b) and as ordered by the court, the convicted person shall repay the amount of excess benefits or payments received under the program, plus interest on the amount at the maximum legal rate. (iv)Services provided to individuals residing in personal care homes and domiciliary care homes. Del Borrello v. Department of Public Welfare, 508 A.2d 368 (Pa. Cmwlth. If, after investigation, the Department determines that a provider has submitted or has caused to be submitted claims for payments which the provider is not otherwise entitled to receive, the Department will, in addition to the administrative action described in 1101.821101.84 (relating to administrative procedures), refer the case record to the Medicaid Fraud Control Unit of the Department of Justice for further investigation and possible referral for prosecution under Federal, State and local laws. (9)Had a controlled drug license withdrawn or failed to report to the Department changes in the Providers Drug Enforcement Agency Number. (4)The Notice of Appeal shall include a copy of the letter of termination, state the actions being appealed and explain in detail the reasons for the appeal. (3)Not in an amount that exceeds the recipients needs. (a)Except as provided in subsection (b), if a provider discovers that the Department has underpaid the provider under this part, or that a recipient has other coverage for a service for which the Department has made a payment, the provider shall be paid the amount of the underpayment or shall reimburse the Department the amount of the overpayment according to the instructions in the provider handbook. ProgramThe MA program of the Commonwealth. For purposes of this section, time frames referred to are indicated in calendar days. Immediately preceding text appears at serial page (75057). The provider shall repay the amount of the overpayment within 6 months of the date the Comptroller notifies the provider of the overpayment. (a)Request for approval. MAMedical Assistance. Subject to the provisions of this subchapter, no qualified individual shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subject to discrimination by any such entity. (2)If the Department has terminated a providers enrollment and participation for an additional cause unrelated to the conviction or disciplinary action as specified in 1101.77(b)(3) (relating to enforcement actions by the Department), the provider may only appeal the period of the termination attributable to that additional cause. (1)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. The method of repayment is determined by the Department. (2)Invoice adjustments to correct clerical errors or to reduce the amount billed to the maximum fee allowed by the Department. (2)Physicians services as specified in Chapter 1141. The provisions of this 1101.63 amended August 10, 1984, effective September 1, 1984, 14 Pa.B. If the provider chooses to repay by check but fails to do so as agreed, the Department reserves the right to refuse to allow the provider to elect a direct repayment plan, other than immediate direct repayment in response to the cost settlement letter, if an overpayment is discovered for subsequent cost reporting periods. (2)If the Department takes action, it will issue a Notice of Exclusion to the nonparticipating former provider stating the basis for the action, the effective date, whether the Department will consider re-enrollment, and, if so, the date when the request for re-enrollment will be considered. Legal tools for community businesses and nonprofits. (iii)Services furnished to an individual who is a patient in a long term care facility, an intermediate care facility for the mentally retarded or other related conditions, as defined in 42 CFR 435.1009 (relating to definitions relating to institutional status) or other medical institution if the individual is required as a condition of receiving services in the institution, to spend all but a minimal amount of his income for medical care costs. The prohibition includes a pharmacy placing by loan, gift or rental a facsimile machine in a nursing facility for the purpose of transmitting MA prescriptions. Clarification of the terms written and signaturestatement of policy. Enter the email address you signed up with and we'll email you a reset link. Some providers may have their invoices reviewed prior to payment. Postpartum periodThe period beginning on the last day of the pregnancy and extending through the end of the month in which the 60-day period following termination of the pregnancy ends. 4653. To request re-enrollment, the provider shall send a written request to the Departments Office of Medical Assistance, Bureau of Provider Relations. This section cited in 55 Pa. Code 5221.43 (relating to quality assurance and utilization review). This section provides the administrative remedy for providers whose bills have been rejected for payment by the Department, and failure of the Department to afford this avenue of relief may result in an equitable estoppel preventing the Department from claiming these bills were not timely submitted. (1)Reassignment of payment. changes effective through 52 Pa.B. Immediately preceding text appears at serial page (69575). This section cited in 55 Pa. Code 1121.41 (relating to participation requirements); 55 Pa. Code 1123.41 (relating to participation requirements); 55 Pa. Code 1127.41 (relating to participation requirements); 55 Pa. Code 1128.41 (relating to participation requirements); 55 Pa. Code 1141.41 (relating to participation requirements); 55 Pa. Code 1142.41 (relating to participation requirements); 55 Pa. Code 1143.41 (relating to participation requirements); 55 Pa. Code 1144.41 (relating to participation requirements); 55 Pa. Code 1149.41 (relating to participation requirements); and 55 Pa. Code 1251.41 (relating to participation requirements). (3)Failed to comply with the conditions of participation listed in Articles IV or XIV of the Public Welfare Code (62 P. S. 401493 and 14011411). The State Board of Pharmacy will continue to regulate the proper use of facsimile machines. (ii)The provider shall include in the notice of the agreement of sale the effective date of the sale and a copy of the sales agreement. How Formed (Repealed). AdultAn MA recipient 21 years of age or older. Nayak v. Department of Public Welfare, 529 A.2d 557 (Pa. Cmwlth. (2)If the provider does not submit an acceptable repayment plan to the Department or fails to respond to the cost settlement letter within the specified time period, the Department will offset the overpayment amount against the providers MA payments until the overpayment is satisfied. The Department will only pay for medically necessary compensable services and items in accordance with this part and Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule. Payment may be made to practitioners professional corporations or partnerships if the professional corporation or partnership is composed of like practitioners. (c)A physician may not bill the recipient or another provider/person for services for which the Department has requested restitution. (4)This paragraph applies to overpayments relating to cost reporting periods ending prior to October 1, 1985. (ii)Ambulatory surgical center services as specified in Chapter 1126. Provider participation and registration of shared health facilities. Alterations of the record shall be signed and dated. Written requests to participate in the MA Program should be sent to the Departments Office of MA, Bureau of Hospital and Outpatient Programs. . CHAPTER 11 GENERAL PROVISIONS Sec. (13)Make a false statement in the application for enrollment or reenrollment in the program. (a)In-state providers. (1)The Department may terminate the enrollment and direct and indirect participation of, and suspend payments to, any provider upon 30 days advance notice for the convenience or best interest of the Department. 3653; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. Where a person receives MA for which he would have been ineligible due to possession of the unreported property, and proof of date of acquisition of the property is not provided, it shall be deemed that the personal property was held by the recipient the entire time he was on Medical Assistance, and reimbursement shall be for MA paid for the recipient or the value of the excess property, whichever is less. (8)Chapter 1229 (relating to health maintenance organization services). (xxiv)Screenings provided under the EPSDT Program. (a)It shall be unlawful for a person to commit any of the following acts: (1)Knowingly or intentionally make or cause to be made a false statement or representation of a material fact in an application for a benefit or payment. (5)Rejection of an application to re-enroll a terminated or excluded provider prior to the date the Department specified that it would consider re-enrollment. (iii)Other State and local agencies involved in providing health care. This does not preclude a provider from owning or investing in a building in which space is leased for adequate and fair consideration to other providers nor does it prohibit an ophthalmologist or optometrist from providing space to an optician in his office. This chapter sets forth the MA regulations and policies which apply to providers. For the purposes of prior authorization, emergency situations are those which meet the Federal Medicaid definition of medical emergency as it may be amended in the future. (16)Chapter 1143 (relating to podiatrists services). The notice shall be sent to the Office of MA, Bureau of Provider Relations. Although termination of the written provider agreement is the only sanction expressly provided for in subsection (e)(4), the Department has the right to impose a lesser included penalty of suspension of that agreement. (iii)A participating provider is paid for services or items prescribed or ordered by a provider who voluntarily withdraws from the program. (a)For overpayments relating to cost reporting periods ending prior to October 1, 1985, which were not appealed prior to February 6, 1988, the Department will use its current policy specified in 1101.84(b)(4) and (5) and 1181.101(f) (relating to provider right of appeal; and facilitys right to a hearing). The planning of transport provision may be improved in co-operation schools so that there are identifiable safe walking and cycle routes, and that access to public transport is good and safe. Moreover, several provisions in the Pennsylvania School Code define the term "school entity" as encompassing intermediate unites. (vi)Ambulance services as specified in Chapter 1245, for medically necessary emergency transportation and transportation to a nonhospital drug and alcohol detoxification and rehabilitation facility from a hospital when a recipient presents to the hospital for inpatient drug and alcohol treatment and the hospital has determined that the required services are not medically necessary in an inpatient facility. The provisions of this 1101.77a adopted December 13, 1996, effective December 14, 1996, 26 Pa.B. (iv)The applicable professional licensing board. (xiv)Services furnished by a funeral director. (9)Submit a claim for a service or item at a fee that is greater than the providers charge to the general public. (1)Eligibility determination was requested within 60 days of the date of service and the Department has received an invoice exception request from the provider within 60 days of receipt of the eligibility determination. provisions 1101 and 1121 of pennsylvania school code . (xxiii)Medical examinations when requested by the Department. 2926; amended January 22, 1988, effective January 23, 1988, 18 Pa.B. A medically needy school child is eligible for benefits available to categorically needy recipients if the benefits are required to treat a health problem noted in his school medical record. 1985). Please help us improve our site! (6)An appeal by the provider of the Departments action to offset the overpayment against the providers MA payments when the provider fails either to respond timely to the cost settlement letter or to pay the overpayment directly when due will not stay the Departments action. (4)The solicitation or receipt or offer of a kickback, payment, gift, bribe or rebate for purchasing, leasing, ordering or arranging for or recommending purchasing, leasing, ordering or arranging for or recommending purchasing, leasing or ordering a good, facility, service or item for which payment is made under MA. To be acceptable, a direct repayment or offset plan shall ensure that the total overpayment amount is repaid to the Department by the date on which the Department is required to credit the Federal government with the Federal share of the overpayment, not including an administrative processing period that may be granted to the Department under Federal procedures for completing the Medicaid expenditure report. Similarly, a claim which appears as a pend on a remittance advice and does not subsequently appear as an approved or rejected claim before the expiration of an additional45 days should be resubmitted immediately by the provider. If the Departments notice of termination or exclusion specifies a date after which the Department will consider re-enrolling the provider, the Department will, under no circumstances, consider re-enrolling the provider before the specified date. Eisenberg v. Department of Public Welfare, 516 A.2d 333 (Pa. 1986). The fact that this section requires physicians to maintain records for 4 years does not preclude the Department of Public Welfare from using available records which are more than 4 years old in the course of a civil proceeding leading to the termination of a physicians participation in the MA Program. Of facsimile machines MA fee is under $ 2 for enrollment or reenrollment in the providers Enforcement! Until he returned home 2002 ) ; appeal denied 839 A.3d 354 ( Pa. 2003 ) provider Relations &... Code 5221.43 ( relating to utilization control ) 2926 ; amended January 22, 1988 effective. Assistance, Bureau of provider Relations 13 ) Make a false statement in application. Withdraws from the Program denied 839 A.3d 354 ( Pa. Cmwlth for the MA and... 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