Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1101 - GENERAL PROVISIONS
FEES AND PAYMENTS
Section 1101.71 - Utilization control

Universal Citation: 55 PA Code ยง 1101.71

Current through Register Vol. 54, No. 44, November 2, 2024

(a) The Department, in accordance with section 1902(a)(30) of the Social Security Act (42 U.S.C.A. § 1396(a)(30)), has established procedures for reviewing the utilization of, and payment for, Medical Assistance services. Providers are required, upon request, to furnish the Department or its designated agents, the Office of the Attorney General or the Secretary of Health and Human Services, with medical and fiscal records as specified in § 1101.51(e) (relating to ongoing responsibilities of providers). Providers shall cooperate with audits and reviews made by the Department for the purpose of determining the validity of claims and the reasonableness and necessity of service provided or for any other purpose.

(b) Providers shall submit to the Department or the Secretary of Health and Human Services or to the Office of the Attorney General of this Commonwealth within 35 days of request, information related to business transactions which shall include complete information about:

(1) The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and

(2) Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.

This section cited in 55 Pa. Code § 1101.43 (relating to enrollment and ownership reporting requirements); 55 Pa. Code § 1127.71 (relating to scope of claims review procedures); 55 Pa. Code § 1128.71 (relating to scope of claims review procedures); 55 Pa. Code § 1181.542 (relating to who is required to be screened); 55 Pa. Code Chapter 1181 Appendix O (relating to OBRA sanctions); and 55 Pa. Code § 5221.43 (relating to quality assurance and utilization review).

Disclaimer: These regulations may not be the most recent version. Pennsylvania may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.