Current through Register Vol. 53, No. 52, December 30, 2023
(a) A nursing facility has a right to appeal
and have a hearing if the nursing facility does not agree with the Department's
decision regarding:
(1) The peer group prices
established annually by the Department for the peer group in which the nursing
facility is included. The nursing facility may appeal the peer group prices
only as to the issue of whether the peer group prices were calculated in
accordance with §
1187.96 (relating to price and
rate setting computations).
(i) A nursing
facility may not challenge the validity or accuracy of any adjustment (except
as provided in §
1187.141(10)) or
any desk or field audit findings relating to the database or total facility
CMIs used by the Department in calculating the peer group prices as a basis for
its appeal of the peer group prices.
(ii) If more than one nursing facility in a
peer group appeals the peer group prices established by the Department, the
Office of Hearings and Appeals may consolidate for hearing the appeals relating
to each peer group.
(2)
The findings issued by the Department in a desk or field audit of the nursing
facility's MA-11 cost report.
(3)
The Department's denial, nonrenewal or termination of the nursing facility's MA
provider agreement.
(4) The MA CMI
established quarterly by the Department for the facility.
(5) The Department's imposition of sanctions
or fines on the nursing facility under Subchapter I (relating to enforcement of
compliance for nursing facilities with deficiencies).
(6) The total facility CMI established
annually by the Department for the nursing facility.
(7) The rate established annually by the
Department for the nursing facility for resident care cost, other resident
related cost, administrative cost and capital cost.
(8) The quarterly adjustment made by the
Department to the nursing facility's rate based upon the facility's MA CMI. The
facility may appeal the quarterly rate adjustment only as to the issue of
whether the quarterly rate adjustment was calculated correctly.
(9) The disproportionate share incentive
payment made annually by the Department to the nursing facility. A nursing
facility may appeal its disproportionate share incentive payment only as to the
issue of whether the Department used the correct number of MA days of care and
the correct inflation factor in calculating the facility's payment.
(10) A retrospective gross adjustment made
under §
1187.108 (relating to gross
adjustments to nursing facility payments), for the peer group in which the
nursing facility is included. The nursing facility may appeal the gross
adjustment only as to the issue of whether the adjustment was calculated in
accordance with a final administrative action or court order.
(i) A nursing facility may not challenge the
validity or accuracy of the underlying action or order which resulted in the
retrospective gross adjustment.
(ii) If more than one nursing facility in a
peer group appeals a retrospective gross adjustment, the Office of Hearings and
Appeals may consolidate for hearing the appeals relating to each peer
group.
(b) A
nursing facility appeal is subject to §
1101.84 (relating to provider
right of appeal).
(c) A nursing
facility's appeal shall be filed within the following time limits:
(1) A nursing facility's appeal of the peer
group prices shall be filed within 30 days of the date on which the Department
publishes the peer group price in the Pennsylvania
Bulletin.
(2) A nursing
facility's appeal of the decisions listed in subsection (a)(2)-(10) shall be
filed within 30 days of the date of the Department's letter transmitting or
notifying the facility of the decision.
(d) A nursing facility's appeal shall meet
the following requirements:
(1) A nursing
facility's appeal shall be in writing, shall identify the decision appealed
and, in appeals involving decisions identified in subsection (a)(2)-(10), shall
enclose a copy of the Department's letter transmitting or notifying the nursing
facility of the decision.
(2) A
nursing facility's appeal shall state in detail the reasons why the facility
believes the decision is factually or legally erroneous and the specific issues
that the facility will raise in its appeal, including issues relating to the
validity of Department regulations. In addition, a nursing facility appeal of
findings in a desk or field audit report shall identify the specific findings
that the facility believes are erroneous and the reasons why the findings are
erroneous. Reasons and issues not stated in a nursing facility's appeal shall
be deemed waived and will not be considered in the appeal or any subsequent
related appeal, action or proceeding involving the same decision. Desk or field
audit findings not identified in a nursing facility appeal will be deemed final
and will not be subject to challenge in the appeal or any subsequent related
appeal, action or proceeding involving the same desk or field audit.
(3) A nursing facility may amend its appeal
in order to meet the requirements of paragraph (2). A nursing facility shall
file its amended appeal within 90 days of the date of the decision appealed. An
amended appeal shall be permitted only if the nursing facility's appeal was
filed in accordance with the time limits set forth in subsection (c). No
subsequent amendment of an appeal will be permitted except under §
1187.1(d) (relating to policy).
(e) An appeal or an amended appeal shall be
mailed to the Executive Director, Office of Hearings and Appeals, Department of
Human Services, Post Office Box 2675, Harrisburg, Pennsylvania 17105. The date
of filing is the date of receipt of the appeal or amended appeal by the Office
of Hearings and Appeals.
(f) The
Department may reopen an audit or a prior year's audit if an appeal is
filed.
This section cited in 55 Pa. Code §
41.3 (relating to definitions); 55
Pa. Code §
1187.75 (relating to final
reporting); 55 Pa. Code §
1187.113b (relating to capital
cost reimbursement waivers-statement of policy); 55 Pa. Code §
1187.115 (relating to adjustments
relating to errors and corrections of nursing facility payments); and 55 Pa.
Code §
1187.158 (relating to
appeals).
