Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1187 - NURSING FACILITY SERVICES
Subchapter K - EXCEPTIONAL PAYMENT FOR NURSING FACILITY SERVICES
Section 1187.158 - Appeals
Universal Citation: 55 PA Code ยง 1187.158
Current through Register Vol. 54, No. 44, November 2, 2024
(a) Appeals. An appeal may be filed by the resident or the resident's authorized representative, by the nursing facility, or by both, from the Department's decision to deny, terminate or suspend a grant, subject to the following:
(1) If the Department denies a
grant because the DME is not exceptional DME, an appeal of the denial may be
filed solely on the basis that the DME is exceptional DME as defined in §
1187.2 (relating to
definitions).
(2) If the Department
automatically terminates a grant under §
1187.157(a)(1)
(relating to termination or suspension of exceptional DME grants and recovery
of exceptional payments), an appeal of the termination may be filed solely on
the basis that none of the conditions specified in §
1187.157(a)(1)(i)-(vi) has occurred.
(3) If a resident appeals the denial,
termination or suspension of a grant, Chapter 275 (relating to appeal and fair
hearing and administrative disqualification hearings) applies.
(4) If a nursing facility appeals the denial,
termination or suspension of a grant, §
1187.141(b), (d) and
(e) (relating to nursing facility's right to
appeal and to a hearing) apply.
(5)
An appeal from the Department's decision denying a request for a grant shall be
received in the Department's Bureau of Hearings and Appeals within 30 days of
the date of the Department's written notice.
(6) If the resident or the nursing facility
timely appeals the Department's decision to deny, suspend or terminate a grant,
the Department's decision is not final until the Department issues a final
adjudication on the appeal.
(b) Effect of decisions.
(1)
Effect on subsequent grant
requests. The denial or termination of a grant, does not prohibit a
nursing facility from submitting a new request for an exceptional DME grant for
the same resident, if the nursing facility determines that there has been a
change in the resident's condition since the denial or termination.
(2)
Effect on services.
(i) If the Department determines that DME
specified in the nursing facility's request is medically necessary but denies
the request because the DME is not exceptional DME, the nursing facility shall,
as a part of the nursing facility services that it provides to the resident,
provide the DME to the resident, unless the resident refuses the DME,
regardless of whether the nursing facility or resident appeals the Department's
decision. If the resident refuses the DME, the nursing facility shall notify
the Department in accordance with §
1187.22(17)
(relating to ongoing responsibilities of nursing facilities).
(ii) If the Department determines that the
DME specified in the nursing facility's request is exceptional DME but denies
the request because the DME is not medically necessary, the nursing facility
may provide the DME and charge the resident in accordance with and subject to
applicable Federal and state requirements, including
42 CFR
483.10(c)(8) (relating to
resident rights) and §
1101.63(a)
(relating to payment in full), if, after receiving actual notice of the
Department's denial, the resident requests that the nursing facility provide
the DME. If the resident or nursing facility appeals the Department's
determination to deny the exceptional DME grant and the appeal is sustained,
the nursing facility shall refund any payment made by the resident within 60
days from the date of the Department's final adjudication sustaining the
appeal.
(iii) If the Department
terminates a grant or suspends payment under a grant under §
1187.157(a)(2) and
(3), and the resident or the resident's
authorized representative appeals the termination or suspension within
10-calendar days of the date on which the Department's notice was mailed, the
Department will continue to make payments under the grant pending the outcome
of the hearing on the resident's appeal. If, after the hearing, the Department
denies the resident's appeal, the Department will recover any payments made
under the grant on or after the termination date or during the period of
suspension specified in the Department's notice.
(iv) If the Department terminates a grant or
suspends payment under a grant under §
1187.157(a)(2) and
(3), and the resident or the resident's
authorized representative does not appeal the termination or suspension, or
appeals more than 10-calendar days from the date on which the Department's
notice was mailed, the Department will cease payments under the grant on the
termination date or during the period of suspension specified in the
Department's notice.
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