PROVIDER MISUTILIZATION AND ABUSE
§ 22.81. Utilization control.
(a) Enrolled providers are required, upon request, to furnish the Department with medical and fiscal records relating to participation in PACE. Providers shall fully cooperate with audits and reviews made by the Department for the purpose of determining the validity of claims and the reasonableness and necessity of benefits provided or for another purpose.
(b) Providers shall furnish to the Department, within 15-calendar days of request, complete information related to PACE-related business transactions.
(c) Under § 22.84 (relating to administrative actions and penalties), failure of a provider to comply with the Department’s request for information referred to in this section may result in the termination of a provider’s enrollment in the PACE Program.
(d) Enrolled providers shall respond in a complete manner to inquiries by utilization review committees within 7 business days of a committee’s request.
Source The provisions of this § 22.81 adopted December 15, 1984, effective December 16, 1984, 14 Pa.B. 2109; amended March 29, 1985, effective March 30, 1985, 15 Pa.B. 1163; amended December 14, 1990, effective December 15, 1990, 20 Pa.B. 6143. Immediately preceding text appears at serial pages (115963) to (115964).
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