Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1187 - NURSING FACILITY SERVICES
Subchapter D - DATA REQUIREMENTS FOR NURSING FACILITY APPLICANTS AND RESIDENTS
Section 1187.34 - Requirements related to notices and payments pending resident appeals
Universal Citation: 55 PA Code ยง 1187.34
Current through Register Vol. 54, No. 12, March 23, 2024
(a) The requirements relating to notices authorizing and discontinuing MA payments for nursing facility services are as follows:
(1)
Notices authorizing MA payment.
(i) The nursing facility shall retain, in its
business office, a copy of the Department's notice authorizing MA nursing
facility services for each MA conversion resident and for each MA applicant or
recipient who is admitted as a resident.
(ii) The Department's notice authorizing MA
nursing facility services will specify the effective date of coverage and the
amount of money that the resident has available to contribute towards payment.
The nursing facility is responsible to obtain the resident's share of the
payment.
(2)
Notices discontinuing MA payment.
(i) The nursing facility shall retain, in its
business office, a copy of the Department's notice discontinuing payment for MA
nursing facility services for every resident who the Department determines is
no longer eligible to receive MA nursing facility services. The Department's
determination may be based upon a review conducted by the Department or the
resident's attending physician.
(ii) The Department's notice discontinuing
payment for MA nursing facility services will specify the effective date of the
discontinuance of coverage, that the resident may appeal the notice within 30
days and that the resident must appeal within 10-calendar days of the date the
notice was mailed in order for payments to continue pending the outcome of the
hearing on the resident's appeal.
(b) The requirements relating to payments pending resident appeals and recovery of payments subsequent to appeals are as follows:
(1)
Payments pending
appeal.
(i) If the resident or a
representative of the resident appeals the Department's notice discontinuing
payment for MA nursing facility services within 10-calendar days of the date on
which the notice was mailed to the resident, the Department will continue
payments to the nursing facility for nursing facility services rendered to the
resident pending the outcome of the hearing on the resident's appeal subject to
paragraph (2).
(ii) If the resident
or a representative of the resident does not appeal the Department's notice
discontinuing payment for MA nursing facility services, or appeals after
10-calendar days from the date on which the notice was mailed to the resident,
the Department will cease payment to the nursing facility for services rendered
to the resident beginning on the effective date of the discontinuance of
coverage specified in the notice or the date on which the resident was
discharged from the facility, whichever date occurs first.
(2)
Payment recovery for services
rendered pending appeal. If a resident's appeal of a notice of
discontinuance of payment for MA nursing facility services is denied, the
Department will recover payments made to the nursing facility. The period for
which the Department will recover payments will begin on the effective date of
the discontinuance of coverage specified in the notice to the resident and end
on the date on which payments were discontinued as a result of the outcome of
the hearing on the resident's appeal or the date of the resident's discharge
from the facility, whichever date occurs first.
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.
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