Current through Register Vol. 54, No. 44, November 2, 2024
(a) A nursing facility has a right to appeal
and have a hearing if dissatisfied with the Department's decision regarding:
(1) The interim per diem rate established by
the Department, unless a change in the interim per diem rate is made by the
Department based on a revision to the net operating portion of the rate as a
result of a revision to the applicable net operating cost reimbursement
ceiling, in which case the facility may appeal only as to the issue of whether
or not the ceiling used to revise the interim per diem rate is in fact the
established ceiling for the facility's geographical grouping and level of
care.
(2) The findings of the
auditors in the annual audit report.
(3) The determination by the comptroller of
the difference between the allowable costs certified by the auditors in the
annual audit report, and the total allowance amount as shown on the interim
billing.
(4) The denial or
nonrenewal of a provider agreement.
(i) A
skilled nursing facility that has been either denied an MA Provider Agreement
or renewal of the agreement or whose agreement has been terminated in whole or
in part by the Department prior to its expiration date, has the right to a full
evidentiary hearing before a hearing officer to contest the action.
(ii) Facilities participating in Medicare and
the MA Program that are denied renewal of an MA Provider Agreement or have the
agreement terminated by the Department because of termination or nonrenewal by
Medicare are entitled to the review procedures specified for Medicare
facilities in 42 CFR Part 498 (relating to appeals procedures for
determinations that affect participation in the Medicare Program). The final
decision entered as a result of the Medicare review procedures is binding for
the purposes of participation in the MA Program.
(5) The MA Program enhancement payment
consisting of the 2% inflation adjustment of the interim rate or interim cost
settlement made by the Department for Fiscal Years 1992-1993, 1993-1994 and
1994-1995.
(i) The facility's right to appeal
shall be limited to the issue of whether:
(A)
Its MA Program enhancement payment consisting of 2% inflation adjustment of the
facility's interim rate was calculated in accordance with §§
1181.67(1) and
1181.211 (relating to setting
interim per diem rates; and cost reimbursement principles and
method).
(B) Its interim cost
settlement was calculated in accordance with §
1181.69(c)
(relating to annual adjustment).
(ii) This paragraph does not otherwise limit
a facility's right to file an appeal under §
1101.84 (relating to provider
right of appeal) or this section from interim rates established under §
1181.221 (relating to determining
the interim per diem rate) or established as a result of a revision to the
ceilings on net operating costs, or from audit findings or final cost
settlement issued with respect to which an interim cost settlement is
paid.
(6) The MA Program
enhancement payment consisting of the 2% inflation adjustment of the interim
rate made by the Department for the period July 1, 1995, through December 31,
1995. The nursing facility's right to appeal shall be limited to the issue of
whether its MA Program enhancement payment consisting of the 2% inflation
adjustment of the nursing facility's interim rate was calculated in accordance
with §§ 1181.67(1) and 1181.211.
(b) A nursing facility appeal is subject to
§ 1101.84.
(c) An appeal shall
be taken within 30 days of the date that the facility is notified of the
decisions in subsection (a). Findings contained in a facility's audit report
which are not appealed by the facility within the 30-day limit will not be
considered as part of subsequent appeal proceedings.
(d) An appeal shall be mailed to the
Executive Director, Office of Hearings and Appeals, Department of Human
Services, Post Office Box 2675, DHS Complex, 6th Floor, Harrisburg,
Pennsylvania 17105, with a copy to the Office of Legal Counsel. The appeal
request shall specify the issues presented for review.
(e) The Audit Division of the Bureau of Long
Term Care Programs may reopen a prior year's audit if an appeal is
filed.
(f) For cost reporting
periods ending prior to October 1, 1985, if an analysis of the facility's audit
report by the Office of the Comptroller discloses that an overpayment has been
made to the facility, the facility will be bound by §
1101.84(b)(4) and
(5).
The provisions of this §1181.101 amended under sections
201, 403 and 443.1(2) and (3) of the Public Welfare Code (62 P. S. §§
201,
403 and
443.1(2) and
(3)).
This section cited in 55 Pa. Code §
1101.69a (relating to
establishment of a uniform period for the recoupment of overpayments from
providers (COBRA)); and 55 Pa. Code §
1181.75 (relating to auditing
requirements related to patient fund
management).
