§ 1101.42. Prerequisites for participation.
(a) In-state providers. In order to be eligible to participate in the MA Program, Commonwealth-based providers shall be currently licensed and registered or certified or both by the appropriate State agency, complete the enrollment form, sign the provider agreement specified by the Department, and meet additional requirements described in this chapter and the separate chapters relating to each provider type. The Department may at its discretion refuse to enter into a provider agreement. Each individual practitioner or medical facility shall have a separate provider agreement with the Department.
(b) Out-of-State providers. Out-of-State providers shall be licensed, and registered or certified or both, by the appropriate agencies in their respective states. A provider shall also be currently participating in the Medicaid program of his state if it has one. Providers in states adjacent to this Commonwealth who regularly furnish services to Pennsylvania MA recipients shall be required to enter into a written provider agreement. A service an out-of-State provider renders to a Pennsylvania MA recipient shall be subject to the regulations of the MA Program of the Commonwealth.
(c) Providers or applicants ineligible for program participation. Providers whose provider agreements have been terminated by the Department or who have been excluded from the Medicare program or any other state’s Medicaid program are not eligible to participate in this Commonwealth’s MA Program during the period of their termination. Providers who are ineligible under this subsection are subject to the restrictions in § 1101.77(c) (relating to enforcement actions by the Department).
Source The provisions of this § 1101.42 amended November 18, 1983, effective November 19, 1983, 13 Pa.B. 3653. Immediately preceding text appears at serial pages (75054) and (75055).
Notes of Decisions Waiver
Where the Department had created confusion regarding whether or not the Department of Health approval was required for certain Medical Assistance Program health-care providers’ facilities, and where the Department had sua sponte waived the approval requirement for a short period of time the Department abused its discretion in refusing to extend the waiver to encompass the full period of time necessary for the providers to obtain Department of Health approval. Eye and Ear Hospital v. Department of Public Welfare, 514 A.2d 976 (Pa. Cmwlth. 1986).
Cross References This section cited in 55 Pa. Code § 1101.42a (relating to policy clarification regarding physician licensure—statement of policy); 55 Pa. Code § 1121.41 (relating to participation requirements); 55 Pa. Code § 1123.41 (relating to participation requirements); 55 Pa. Code § 1127.41 (relating to participation requirements); 55 Pa. Code § 1128.41 (relating to participation requirements); 55 Pa. Code § 1130.51 (relating to provider enrollment requirements); 55 Pa. Code § 1141.41 (relating to participation requirements); 55 Pa. Code § 1142.41 (relating to participation requirements); 55 Pa. Code § 1143.41 (relating to participation requirements); 55 Pa. Code § 1144.41 (relating to participation requirements); 55 Pa. Code § 1149.41 (relating to participation requirements); 55 Pa. Code § 1187.21a (relating to nursing facility exception requests—statement of policy); 55 Pa. Code § 1225.44 (relating to participation requirements for out-of-State family planning clinics); and 55 Pa. Code § 1251.41 (relating to participation requirements).
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