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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1032 (February 24, 2024).

34 Pa. Code § 127.301. Referral standards.


§ 127.301. Referral standards.

 (a)  Under section 306(f.1)(3)(iii) of the act (77 P. S. §  531(3)(iii)), a provider may not refer a person for certain treatment and services if the provider has a financial interest with the person or in the entity that receives the referral. A provider may not enter into an arrangement or scheme, such as a cross-referral arrangement, which the provider knows, or should know, has a principal purpose of assuring referrals by the provider to a particular entity which, if the provider directly made referrals to the entity, would be in violation of the act.

 (b)  No claim for payment may be presented by a person, provider or entity for a service furnished under a referral prohibited under subsection (a).

 (c)  Referrals permitted under all present and future Safe Harbor regulations promulgated under the Medicare and Medicaid Patient and Program Protection Act at 42 U.S.C.A. §  1320a-7b(1) and (2), published at 42 CFR 1001.952 (relating to exceptions), and all present and future exceptions to the Stark amendments to the Medicare Act at 42 U.S.C.A. §  1395nn, and all present and future regulations promulgated thereunder are not prohibited referrals involving financial interest. An insurer may not deny payment to a health care provider involved in such transaction or referral.

 (d)  For purposes of section 306(f.1)(3)(iii) of the act, a CCO will be considered a single health care provider.

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