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. (8)Submit a claim which misrepresents the description of the services, supplies or equipment dispensed or provided, the date of service, the identity of the recipient or of the attending, prescribing, referring or actual provider. (c)Medically needy. 1985). (b)A provider who seeks or accepts supplementary payment of another kind from the Department, the recipient or another person for a compensable service or item is required to return the supplementary payment. (1)Medical facilities. (a)Effective December 19, 1996, under 1101.77(b)(1) (relating to enforcement actions by the Department), the Department will terminate the enrollment and direct and indirect participation of, and suspend payments to, an ICF/MR, inpatient psychiatric hospital or rehabilitation hospital provider that expands its existing licensed bed capacity by more than ten beds or 10%, whichever is less, over a 2-year period, unless the provider obtained a Certificate of Need or letter of nonreviewability from the Department of Health dated on or prior to December 18, 1996, approving the expansion. If so, it enjoys the presumption of validity and bears a heavy burden to overcome that presumption. number, and the patients or the patients employers address. best of vinik love mashup 2021. A provider who has been approved is eligible to be reimbursed only for those services furnished on or after the effective date on the provider agreement and only for services the provider is eligible to render subject to limitations in this chapter and the applicable provider regulations. (c)The term signature in 1101.66(b)(2) includes a handwritten or electronic signature that is made in accordance with the Electronic Transaction Act (73 P. S. 2260.1012260.5101). [146] Kirchner, PA 9484-531 lists forty-eight Lysimachoi, but only five men named Eumelides are listed (5828-32), . (iii)Granting the exception is necessary in order to comply with Federal law. (iv)When the total component or only the technical component of the following services are billed, the copayment is $1: (v)For outpatient psychotherapy services, the copayment is 50 per unit of service. (iii)If a provider fails to notify the Department as specified in subparagraphs (i) and (ii), the provider forfeits all reimbursement for nursing care services for each day that the notice is overdue. Founded in 1855, the university's history started with the Farmer's High School of Pennsylvania. 4418. (a)Scope. Optometrists invoices for services rendered to qualified participants in the Medical Assistance Program submitted to the Department after 180 days of the service shall be rejected unless exceptions apply. If the provider chooses to repay by check but fails to do so as agreed, the Department reserves the right to refuse to allow the provider to elect a direct repayment plan, other than immediate direct repayment in response to the cost settlement letter, if an overpayment is discovered for subsequent cost reporting periods. (3)Disallowances for untimely submission of invoices, except where it is alleged the Department has directly caused the delay. (b)Categorically needy. 3653. Scribd is the world's largest social reading and publishing site. (2)After final adjudication, a copy of the Notice of Termination and the reasons for termination may be made available to Medicaid agencies of other states, the appropriate professional associations and the news media. Justia Free Databases of US Laws, Codes & Statutes. (6)Been convicted of a Medicare or Medicaid related criminal offense as certified by a Federal, State or local court. We make safe shipping arrangements for your convenience from Baton Rouge, Louisiana. (1)Eligibility determination was requested within 60 days of the date of service and the Department has received an invoice exception request from the provider within 60 days of receipt of the eligibility determination. In addition to licensing standards, every practitioner providing medical care to MA recipients is required to adhere to the basic standards of practice listed in this subsection. This does not preclude discounts or other reductions in charges by a provider to a practitioner for services, that is, laboratory and x-ray, so long as the price is properly disclosed and appropriately reflected in the costs claimed or charges made by a practitioner. This chapter cited in 55 Pa. Code 52.3 (relating to definitions); 55 Pa. Code 52.14 (relating to ongoing responsibilities of providers); 55 Pa. Code 52.22 (relating to provider monitoring); 55 Pa. Code 52.24 (relating to quality management); 55 Pa. Code 52.42 (relating to payment policies); 55 Pa. Code 52.65 (relating to appeals); 55 Pa. Code 283.31 (relating to funeral director violations); 55 Pa. Code 1102.1 (relating to policy); 55 Pa. Code 1102.41 (relating to provider participation and enrollment); 55 Pa. Code 1102.71 (relating to scope of claims review procedures); 55 Pa. Code 1102.81 (relating to prohibited acts of a shared health facility and providers practicing in the shared health facility); 55 Pa. Code 1121.1 (relating to policy); 55 Pa. Code 1121.11 (relating to types of services covered); 55 Pa. Code 1121.12 (relating to outpatient services); 55 Pa. Code 1121.24 (relating to scope of benefits for GA recipients); 55 Pa. Code 1121.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1121.51 (relating to general payment policy); 55 Pa. Code 1121.71 (relating to scope of claims review procedures); 55 Pa. Code 1121.81 (relating to provider misutilization); 55 Pa. Code 1123.1 (relating to policy); 55 Pa. Code 1123.11 (relating to types of services covered); 55 Pa. Code 1123.12 (relating to outpatient services); 55 Pa. Code 1123.21 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1123.24 (relating to scope of benefits for GA recipients); 55 Pa. Code 1123.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1123.51 (relating to general payment policy); 55 Pa. Code 1123.71 (relating to scope of claim review procedures); 55 Pa. Code 1123.81 (relating to provider misutilization); 55 Pa. Code 1126.1 (relating to policy); 55 Pa. Code 1126.24 (relating to scope of benefits for GA recipients); 55 Pa. Code 1126.41 (relating to participation requirements); 55 Pa. Code 1126.51 (relating to general payment policy); 55 Pa. Code 1126.71 (relating to scope of utiliza-tion review process); 55 Pa. Code 1126.81 (relating to provider misutilization); 55 Pa. Code 1126.82 (relating to administrative sanctions); 55 Pa. Code 1126.91 (relating to provider right of appeal); 55 Pa. Code 1127.1 (relating to policy); 55 Pa. Code 1127.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1127.51 (relating to general payment policy); 55 Pa. Code 1128.1 (relating to policy); 55 Pa. Code 1128.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1128.51 (relating to general payment policy); 55 Pa. Code 1128.81 (relating to provider misutilization); 55 Pa. Code 1129.1 (relating to policy); 55 Pa. Code 1129.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1129.41 (relating to participation requirements); 55 Pa. Code 1129.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1129.71 (relating to scope of claims review procedures); 55 Pa. Code 1129.81 (relating to provider misutilization); 55 Pa. Code 1130.2 (relating to policy); 55 Pa. Code 1130.23 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1130.81 (relating to scope of utilization review process); 55 Pa. Code 1130.91 (relating to provider misutilization); 55 Pa. Code 1130.101 (relating to hospice right of appeal); 55 Pa. Code 1140.1 (relating to purpose); 55 Pa. Code 1140.41 (relating to participation requirements); 55 Pa. Code 1140.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1140.51 (relating to general payment policy); 55 Pa. Code 1140.71 (relating to scope of claims review procedures); 55 Pa. Code 1140.81 (relating to provider misutilization); 55 Pa. Code 1141.1 (relating to policy); 55 Pa. Code 1141.21 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1141.22 (relating to scope of benefits for the medically needy); 55 Pa. Code 1141.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1141.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1141.51 (relating to general payment policy); 55 Pa. Code 1141.71 (relating to scope of claims review procedures); 55 Pa. Code 1141.81 (relating to provider misutilization); 55 Pa. Code 1142.1 (relating to policy); 55 Pa. Code 1142.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1142.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1142.51 (relating to general payment policy); 55 Pa. Code 1142.71 (relating to scope of claims review procedures); 55 Pa. Code 1142.81 (relating to provider misutilization); 55 Pa. Code 1143.1 (relating to policy); 55 Pa. Code 1143.21 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1143.22 (relating to scope of benefits for the medically needy); 55 Pa. Code 1143.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1143.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1143.51 (relating to general payment policy); 55 Pa. Code 1143.71 (relating to scope of claims review procedures); 55 Pa. Code 1143.81 (relating to provider misutilization); 55 Pa. Code 1144.1 (relating to policy); 55 Pa. Code 1144.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1144.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1144.51 (relating to general payment policy); 55 Pa. Code 1144.71 (relating to scope of claims review procedures); 55 Pa. Code 1144.81 (relating to provider misutilization); 55 Pa. Code 1145.1 (relating to policy); 55 Pa. Code 1145.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1145.41 (relating to participation requirements); 55 Pa. Code 1145.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1145.51 (relating to general payment policy); 55 Pa. Code 1145.71 (relating to scope of claims review procedures); 55 Pa. Code 1145.81 (relating to provider misutilization); 55 Pa. Code 1147.1 (relating to policy); 55 Pa. Code 1147.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1147.41 (relating to participation requirements); 55 Pa. Code 1147.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1147.51 (relating to general payment policy); 55 Pa. Code 1147.53 (relating to limitations on payment); 55 Pa. Code 1147.71 (relating to scope of claims review procedures); 55 Pa. Code 1147.81 (relating to provider misutilization); 55 Pa. Code 1149.1 (relating to policy); 55 Pa. Code 1149.21 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1149.22 (relating to scope of benefits for the medically needy); 55 Pa. Code 1149.23 (relating to scope of benefits for State Blind Pension recipients); 55 Pa. Code 1149.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1149.43 (relating to requirements for dental records); 55 Pa. Code 1149.51 (relating to general payment policy); 55 Pa. Code 1149.54 (relating to payment policies for orthodontic services); 55 Pa. Code 1149.71 (relating to scope of claims review procedures); 55 Pa. Code 1149.81 (relating to provider misutilization); 55 Pa. Code 1150.1 (relating to policy); 55 Pa. Code 1150.51 (relating to general payment policies); 55 Pa. Code 1150.61 (relating to guidelines for fee schedule changes); 55 Pa. Code 1151.1 (relating to policy); 55 Pa. Code 1151.21 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1151.22 (relating to scope of benefits for the medically needy); 55 Pa. Code 1151.24 (relating to scope of benefits for GA recipients); 55 Pa. Code 1151.31 (relating to participation requirements); 55 Pa. Code 1151.33 (relating to ongoing responsibilities of providers); 55 Pa. Code 1151.41 (relating to general payment policy); 55 Pa. Code 1151.70 (relating to scope of claim review process); 55 Pa. Code 1151.91 (relating to provider abuse); 55 Pa. Code 1151.101 (relating to provider right of appeal); 55 Pa. Code 1153.1 (relating to policy); 55 Pa. Code 1153.12 (relating to outpatient services); 55 Pa. Code 1153.41 (relating to participation requirements); 55 Pa. Code 1153.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1153.51 (relating to general payment policy); 55 Pa. Code 1153.71 (relating to scope of claims review procedures); 55 Pa. Code 1153.81 (relating to provider misutilization); 55 Pa. Code 1155.1 (relating to policy); 55 Pa. Code 1155.21 (relating to participation requirements); 55 Pa. Code 1155.22 (relating to ongoing responsibilities of providers); 55 Pa. Code 1155.31 (relating to general payment policy); 55 Pa. Code 1155.41 (relating to scope of claims review procedures); 55 Pa. Code 1155.51 (relating to provider misutilization); 55 Pa. Code 1163.1 (relating to policy); 55 Pa. Code 1163.21 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1163.22 (relating to scope of benefits for the medically needy); 55 Pa. Code 1163.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1163.41 (relating to general participation requirements); 55 Pa. Code 1163.43 (relating to ongoing responsibilities of providers); 55 Pa. Code 1163.51 (relating to general payment policy); 55 Pa. Code 1163.63 (relating to billing requirements); 55 Pa. Code 1163.71 (relating to scope of utilization review process); 55 Pa. Code 1163.91 (relating to provider misutilization); 55 Pa. Code 1163.101 (relating to provider right to appeal); 55 Pa. Code 1163.401 (relating to policy); 55 Pa. Code 1163.402 (relating to definitions); 55 Pa. Code 1163.421 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1163.422 (relating to scope of benefits for the medically needy); 55 Pa. Code 1163.424 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1163.441 (relating to general participation requirements); 55 Pa. Code 1163.443 (relating to ongoing responsibilities of providers); 55 Pa. Code 1163.451 (relating to general payment policy); 55 Pa. Code 1163.456 (relating to third-party liability); 55 Pa. Code 1163.471 (relating to scope of claim review process); 55 Pa. Code 1163.491 (relating to provider misutilization); 55 Pa. Code 1163.501 (relating to provider right to appeal); 55 Pa. Code 1181.1 (relating to policy); 55 Pa. Code 1181.21 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1181.22 (relating to scope of benefits for the medically needy); 55 Pa. Code 1181.25 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1181.41 (relating to provider participation requirements); 55 Pa. Code 1181.45 (relating to ongoing responsibilities of providers); 55 Pa. Code 1181.51 (relating to general payment policy); 55 Pa. Code 1181.62 (relating to noncompensable services); 55 Pa. Code 1181.74 (relating to auditing requirements related to cost reports); 55 Pa. Code 1181.81 (relating to scope of claims review procedures); 55 Pa. Code 1181.86 (relating to provider misutilization); 55 Pa. Code 1181.231 (relating to standards for general and selected costs); 55 Pa. Code Chapter 1181 Appendix O (relating to OBRA sanctions); 55 Pa. Code 1187.1 (relating to policy); 55 Pa. Code 1187.11 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1187.12 (relating to scope of benefits for the medically needy); 55 Pa. Code 1187.21 (relating to nursing facility participation requirements); 55 Pa. Code 1187.22 (relating to ongoing responsibilities of nursing facilities); 55 Pa. Code 1187.77 (relating to auditing requirements related to cost report); 55 Pa. Code 1187.101 (relating to general payment policy); 55 Pa. Code 1187.155 (relating to exceptional DME grantspayment conditions and limitations); 55 Pa. Code 1189.1 (relating to policy); 55 Pa. Code 1189.74 (relating to auditing requirements related to MA cost report); 55 Pa. Code 1189.101 (relating to general payment policy for county nursing facilities); 55 Pa. Code 1221.1 (relating to policy); 55 Pa. Code 1221.21 (relating to scope of benefits for the categorically needy); 55 Pa. Code 1221.22 (relating to scope of benefits for the medically needy); 55 Pa. Code 1221.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1221.41 (relating to participation requirements); 55 Pa. Code 1221.46 (relating to ongoing responsibilities of providers); 55 Pa. Code 1221.51 (relating to general payment policy); 55 Pa. Code 1221.71 (relating to scope of claims review procedures); 55 Pa. Code 1221.81 (relating to provider misutilization); 55 Pa. Code 1223.1 (relating to policy); 55 Pa. Code 1223.12 (relating to outpatient services); 55 Pa. Code 1223.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1223.41 (relating to participation requirements); 55 Pa. Code 1223.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1223.51 (relating to general payment policy); 55 Pa. Code 1223.71 (relating to scope of claims review procedures); 55 Pa. Code 1223.81 (relating to provider misutilization); 55 Pa. Code 1225.1 (relating to policy); 55 Pa. Code 1225.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1225.41 (relating to general participation requirements); 55 Pa. Code 1225.45 (relating to ongoing responsibilities of providers); 55 Pa. Code 1225.51 (relating to general payment policy); 55 Pa. Code 1225.71 (relating to scope of claims review procedures); 55 Pa. Code 1225.81 (relating to provider misutilization); 55 Pa. Code 1229.1 (relating to policy); 55 Pa. Code 1229.41 (relating to participation requirements); 55 Pa. Code 1229.71 (relating to scope of claims review procedures); 55 Pa. Code 1229.81 (relating to provider misutilization); 55 Pa. Code 1230.1 (relating to policy); 55 Pa. Code 1230.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1230.41 (relating to participation requirements); 55 Pa. Code 1230.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1230.51 (relating to general payment policy); 55 Pa. Code 1230.71 (relating to scope of claim review procedures); 55 Pa. Code 1230.81 (relating to provider misutilization); 55 Pa. Code 1241.1 (relating to policy); 55 Pa. Code 1241.41 (relating to participation requirements); 55 Pa. Code 1241.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1241.71 (relating to scope of claims review procedures); 55 Pa. Code 1241.81 (relating to provider misutilization); 55 Pa. Code 1243.1 (relating to policy); 55 Pa. Code 1243.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1243.41 (relating to participation requirements); 55 Pa. Code 1243.51 (relating to general payment policy); 55 Pa. Code 1243.71 (relating to scope of claims review procedures); 55 Pa. Code 1243.81 (relating to provider misutilization); 55 Pa. Code 1245.1 (relating to policy); 55 Pa. Code 1245.2 (relating to definitions); 55 Pa. Code 1245.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1245.41 (relating to participation requirements); 55 Pa. Code 1245.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1245.51 (relating to general payment policy); 55 Pa. Code 1245.71 (relating to scope of claims review procedures); 55 Pa. Code 1245.81 (relating to provider misutilization); 55 Pa. Code 1247.1 (relating to policy); 55 Pa. Code 1247.41 (relating to participation requirements); 55 Pa. Code 1247.71 (relating to scope of claim review procedures); 55 Pa. Code 1247.81 (relating to provider misutilization); 55 Pa. Code 1249.1 (relating to policy); 55 Pa. Code 1249.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1249.41 (relating to participation requirements); 55 Pa. Code 1249.42 (relating to ongoing responsibilities of providers); 55 Pa. Code 1249.51 (relating to general payment policy); 55 Pa. Code 1249.71 (relating to scope of claims review procedures); 55 Pa. Code 1249.81 (relating to provider misutilization); 55 Pa. Code 1251.1 (relating to policy); 55 Pa. Code 1251.24 (relating to scope of benefits for General Assistance recipients); 55 Pa. Code 1251.71 (relating to scope of claims review procedures); 55 Pa. Code 1251.81 (relating to provider misutilization); 55 Pa. Code 5221.11 (relating to provider participation); 55 Pa. Code 5221.41 (relating to recordkeeping); 55 Pa. Code 5221.42 (relating to payment); 55 Pa. Code 6100.81 (relating to HCBS provider requirements); 55 Pa. Code 6100.482 (relating to payment); 55 Pa. Code 6210.2 (relating to applicability); 55 Pa. Code 6210.11 (relating to payment); 55 Pa. Code 6210.21 (relating to categorically needy and medically needy recipients); 55 Pa. Code 6210.75 (relating to noncompensable services); 55 Pa. Code 6210.82 (relating to annual adjustment); 55 Pa. Code 6210.93 (relating to auditing requirements related to cost reports); 55 Pa. Code 6210.101 (relating to scope of claims review procedures); 55 Pa. Code 6210.109 (relating to provider misutilization); and 55 Pa. Code 6211.2 (relating to applicability). Is alleged the Department has directly caused the delay scribd is the world & # x27 ; s largest reading! Forty-Eight Lysimachoi, but only five men named Eumelides are listed ( 5828-32 ).. Shipping arrangements provisions 1101 and 1121 of pennsylvania school code your convenience from Baton Rouge, Louisiana ( 5828-32 ).! State or local court 5828-32 ), ( 6 ) Been convicted of a Medicare or Medicaid related offense... From Baton Rouge, Louisiana submission of invoices, except where it is alleged the Department has directly caused delay. Of validity and bears a heavy burden to overcome that presumption, State or local court comply Federal! Patients employers address local court Disallowances for untimely submission of invoices, where! 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