Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Right to appeal from termination of a provider's enrollment and
participation. If a provider's enrollment and participation are
terminated by the Department, the provider may appeal the Department's
decision, subject to the following conditions:
(1) If a provider's enrollment and
participation are terminated by the Department under the provider's termination
or suspension from Medicare or conviction of a criminal act under §
1101.75 (relating to provider
prohibited acts), the provider may appeal the Department's action only on the
issue of identity.
(2) If the
Department has terminated a provider's 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.
(3) A written Notice of
Appeal shall be filed within 30 days of the date of the notice of termination.
The Notice of Appeal will be considered filed on the date it is received by the
Director, Office of Hearings and Appeals.
(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.
(b)
Right to appeal interim per diem
rates, audit disallowances or payment settlements.
(1) A hospital, nursing home or other
provider reimbursed by the Department on the basis of an interim per diem rate
that is retrospectively adjusted on the basis of the provider's cost experience
during the period for which the interim rate is effective can appeal its
interim per diem rate, the results of its annual audit or its annual payment
settlement as follows:
(i) The Notice of
Appeal of an interim rate shall be filed within 30 days of the date of the
letter from the Bureau of Reimbursement Methods, Office of Medical Assistance,
advising the provider of its interim per diem rate.
(ii) The Notice of Appeal from an audit
disallowance shall be filed within 30 days of the date of the letter from the
Bureau of Reimbursement Methods, Office of Medical Assistance, or the Bureau of
State-Aided Audits, Office of the Auditor General, transmitting the provider's
audit report. If a facility fails to appeal from the auditor's findings at
audit, the facility may not contest the finding in another
proceeding.
(iii) The Notice of
Appeal of the final payment settlement shall be appealed within 30 days of the
date of the letter from the Comptroller of the Department, advising the
provider of the final settlement of accounts.
(2) The Notice of Appeal shall include a copy
of the letter establishing the interim per diem rate, the letter forwarding the
audit report or the letter setting forth the payment settlement, as applicable,
to the provider. The Notice of Appeal also shall set forth in detail the
reasons for the appeal.
(3) The
Notice of Appeal will be considered filed on the date it is received by the
Director, Office of Hearings and Appeals.
(4) This paragraph applies to overpayments
relating to cost reporting periods ending prior to October 1, 1985. If an
analysis of a provider's audit report by the Office of the Comptroller
discloses that an overpayment has been made to the provider, the Comptroller of
the Department shall advise the provider of the amount of the overpayment. The
provider shall repay the amount of the overpayment within 6 months of the date
the Comptroller notifies the provider of the overpayment. The repayment period
will commence on the date set forth in the notice from the Comptroller of the
overpayment. If repayment is not made within 6 months, the Department will
recoup the amount of the overpayment from future payments to the
provider.
(5) An appeal of an audit
disallowance does not suspend the provider's obligation to repay the amount of
the overpayment to the Department.
(c)
Right to appeal other action of
the Department. Appeals of other adverse actions of the Department
shall be filed in writing within 30 days of the date of the notice of the
action to the provider. The Notice of Appeal will be considered filed on the
date it is received by the Director, Office of Hearings and Appeals.
The Notice of Appeal shall include a copy of the notice of
adverse action sent to the provider by the Department and shall set forth in
detail the reasons for the appeal.
(d)
Nonappealable actions.
The provider does not have the right to appeal the following:
(1) Disallowances for services or items
provided to noneligible individuals.
(2) Invoice adjustments to correct clerical
errors or to reduce the amount billed to the maximum fee allowed by the
Department.
(3) Disallowances for
untimely submission of invoices, except where it is alleged the Department has
directly caused the delay.
(4)
Disallowances for services or items rendered during a period of nonenrollment
or termination, except on the issue of identity.
(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.
The provisions of this §1101.84 issued under: sections
403(a) and (b), 441.1 and 1410 of the Public Welfare Code (62 P. S.
§§
403(a) and (b),
441.1 and
1410); amended under sections
201 and 443.1 of the Public Welfare Code (62 P. S. §§
201 and
443.1).
This section cited in 55 Pa. Code §
41.3 (relating to definitions); 55
Pa. Code §
1101.69 (relating to
overpayment-underpayment); 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 facility's
right to a hearing); 55 Pa. Code §
1187.113b (relating to capital
cost reimbursement waivers-statement of policy); 55 Pa. Code §
1187.141 (relating to nursing
facility's right to appeal and to a hearing); 55 Pa. Code §
1189.141 (relating to county
nursing facility's 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).
