Subchapter C. PAYMENT FOR SERVICES
GENERAL REQUIREMENTS Sec.
52.41. Provider billing.
52.42. Payment policies.
52.43. Audit requirements.
52.44. Reporting requirements for ownership change.
52.45. Fee schedule rates.
VENDOR GOOD OR SERVICE
52.51. Vendor good or service payment.
52.52. Subcontracting for a vendor good or service.
52.53. Organized health care delivery system.
GENERAL REQUIREMENTS
§ 52.41. Provider billing.
(a) A provider shall submit claims in accordance with § 1101.68 (relating to invoicing for services).
(b) A provider shall use the Department’s designated claims processing system to submit claims.
(c) An applicant may not bill for a service prior to being enrolled as a provider by the Department.
(d) The provider shall enroll in the Department’s designated claims processing system upon receiving notice that the application is approved.
§ 52.42. Payment policies.
(a) Services will be paid as either a fee schedule service under § 52.45 (relating to fee schedule rates) or as a vendor good or service payment under § 52.51 (relating to vendor good or service payment).
(b) The Department will publish services specific to each waiver and the Act 150 program as a notice in the Pennsylvania Bulletin.
(c) The Department will only pay for a service in accordance with this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies).
(d) The Department will only pay for a service in the type, scope, amount, duration and frequency as specified on the participant’s service plan as approved by the Department.
(e) A provider who accepts supplementary payment for an Act 150 service from a source other than the Department shall return the Act 150 payment to the Department. If the supplementary payment pays only a portion of the cost of the Act 150 service, the provider shall return an amount equal to the supplementary payment to the Department. This subsection does not apply to copayments.
(f) The Department will recoup payments which are not made in accordance with this chapter.
(g) The Department may limit the type of service available in accordance with Federal and State laws, the waiver program requirements or Act 150 program requirements.
(h) The Department will not reimburse a provider who renders a service to a participant who does not have an approved service plan for the date when the service was rendered.
(i) To be paid the MA Program fee schedule rate or receive reimbursement for a vendor good or service, a provider shall comply with this chapter.
(j) The Department will not pay for a service which is rendered to a participant who is enrolled in a waiver or the Act 150 program that does not include the service.
§ 52.43. Audit requirements.
(a) A provider shall comply with Federal audit requirements including the following:
(1) The Single Audit Act of 1984 (31 U.S.C.A. § § 7501—7507).
(2) The revised Office of Management and Budget Circular A-133.
(3) Section 74.26 of 45 CFR (relating to non-Federal audits).
(b) A provider which is required to receive a single audit or an audit in accordance with 45 CFR 74.26 shall comply with the audit requirements.
(c) The Department may request a provider to have the provider’s auditor perform an attestation engagement in accordance with any of the following:
(1) Government Auditing Standards issued by the Comptroller General of the United States or the Generally Accepted Government Auditing Standards.
(2) Standards issued by the Auditing Standards Board.
(3) Standards issued by the American Institute of Certified Public Accountants.
(4) Standards issued by the International Auditing and Assurance Standards Board.
(5) Standards issued by the Public Company Accounting Oversight Board.
(6) Standards of successor organizations to those organizations in paragraphs (1)—(5).
(d) The Department or the Department’s designee may perform an attestation engagement in accordance with subsection (c).
(e) The Department may request the provider’s auditor to conduct a performance audit in accordance with the standards in subsection (c).
(f) A provider which is not required to have an attestation agreement in compliance with the Single Audit Act of 1984 during the program year shall maintain auditable records in compliance with this section.
(g) The Department may perform a financial review of a provider.
(h) A provider shall maintain books, records and documents that support:
(1) The type, scope, amount, duration and frequency of service provision.
(2) The dates of service provision.
(3) The fees and reimbursements earned in accordance with Federal and State requirements.
(4) Compliance with the terms and conditions of service provision as outlined in this chapter.
(i) Electronic records are acceptable documentation provided they comply with § 52.15 (relating to provider records) and electronic records are accessible to the auditing agency.
(j) A provider shall make audit documentation available, upon request, to the authorized representatives of the Department or the Department’s designee.
(k) A provider shall retain books, records and documents for inspection, audit or reproduction for at least 5 years after the provider’s fiscal year-end.
(l) The provider shall retain books, records and documents related to the fiscal year for a time period greater than 5 years from the provider’s fiscal year-end if one of the following is applicable:
(1) The Department, Department’s designee or another State or Federal agency has unresolved questions regarding costs or activities.
(2) The books, records or documents are part of an ongoing investigation or legal action.
(3) Required by applicable State or Federal law.
(m) If a provider is completely or partially terminated, the records relating to the services terminated shall be preserved and made available for at least 5 years from the date of a resulting final settlement or termination of provider, whichever is longer.
(n) A provider shall retain records that relate to litigation of the settlement of claims arising out of performance or expenditures under a waiver or the Act 150 program to which an auditor has taken exception, until the litigation, claim or exceptions have reached final disposition or for a period of at least 5 years from the provider’s fiscal year-end, whichever is greater.
(o) The provider shall provide information listed under this section to the Department or Department’s designee upon request.
§ 52.44. Reporting requirements for ownership change.
(a) A provider assuming ownership shall report a change in ownership or control interest of 5% or more in writing to the Department at least 30 days prior to the effective date of the change.
(b) If the provider is unable to report an ownership or controlling interest change at least 30 days prior to the effective date of the change because of an emergency, then the provider shall report the change as soon as possible, but no later than 2 business days after the effective date of the change. The provider shall also inform the Department as to why the provider was unable to report the change 30 days prior to the change’s occurrence.
(c) The provider assuming ownership shall report the following:
(1) Effective date of sale or controlling interest change.
(2) A copy of the sales agreement or other document effectuating the change.
(d) If a provider fails to notify the Department as specified in subsections (a)—(c), the provider shall forfeit payments for each day after the notice was due to the Department.
§ 52.45. Fee schedule rates.
(a) The Department will establish a fee schedule rate for a waiver or Act 150 program service.
(b) The Department will publish the fee schedule rate under the MA Program fee schedule as a notice in the Pennsylvania Bulletin.
(c) The Department will publish a change in the methods and standards for setting a fee schedule rate as a notice in the Pennsylvania Bulletin.
(d) The Department will publish the services specific to each waiver and the Act 150 program as a notice in the Pennsylvania Bulletin.
Cross References This section cited in 55 Pa. Code § 52.42 (relating to payment policies).
VENDOR GOOD OR SERVICE
§ 52.51. Vendor good or service payment.
(a) The Department will only pay for the actual cost of a vendor good or service which may not exceed the amount for a similar vendor good or service charged to the general public.
(b) A provider shall retain documentation of the amount charged for the vendor good or service.
(c) The provider shall submit verification of subsection (b) to the Department upon request.
(d) The Department will publish the list of vendor goods or services as a notice in the Pennsylvania Bulletin.
(e) The Department will publish the list of vendor goods or services specific to each waiver or the Act 150 program as a notice in the Pennsylvania Bulletin.
Cross References This section cited in 55 Pa. Code § 52.42 (relating to payment policies); and 55 Pa. Code § 52.52 (relating to subcontracting for a vendor good or service).
§ 52.52. Subcontracting for a vendor good or service.
(a) Only an OHCDS may subcontract with an entity to purchase a vendor good or service. A provider who subcontracts shall have a written agreement specifying its duties, responsibilities and compensation.
(b) Only a vendor good or service may be subcontracted.
(c) If an OHCDS subcontracts with an entity to provide a vendor good or service, the OHCDS shall ensure the entity complies with § 52.51(a) (relating to vendor good or service payment).
(d) The Department will not pay an administrative fee or additional cost for a vendor good or service subcontracted by an OHCDS.
§ 52.53. Organized health care delivery system.
(a) An OHCDS shall be an SCE in compliance with this chapter.
(b) An OHCDS may not be reimbursed for rendering service coordination services if it contracts with an entity which is listed on the LEIE, EPLS or Medicheck list.
(c) An OHCDS may not be reimbursed for rendering service coordination services if the OHCDS contracts with an entity which employs a person who is listed on the LEIE or EPLS.
(d) An OHCDS shall complete and sign an OHCDS enrollment form.
Cross References This section cited in 55 Pa. Code § 52.28 (relating to conflict free service coordination).
No part of the information on this site may be reproduced for profit or sold for profit.
This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
