Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 51 Pa.B. 1768 (March 27, 2021).

55 Pa. Code § 1101.71. Utilization control.

§ 1101.71. Utilization control.

 (a)  The Department, in accordance with section 1902(a)(30) of the Social Security Act (42 U.S.C.A. §  1396(a)(30)), has established procedures for reviewing the utilization of, and payment for, Medical Assistance services. Providers are required, upon request, to furnish the Department or its designated agents, the Office of the Attorney General or the Secretary of Health and Human Services, with medical and fiscal records as specified in §  1101.51(e) (relating to ongoing responsibilities of providers). 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.

 (b)  Providers shall submit to the Department or the Secretary of Health and Human Services or to the Office of the Attorney General of this Commonwealth within 35 days of request, information related to business transactions which shall include complete information about:

   (1)  The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and

   (2)  Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.

Source

   The provisions of this §  1101.71 amended November 18, 1983, effective November 19, 1983, 13 Pa.B. 3653. Immediately preceding text appears at serial page (47804).

Cross References

   This section cited in 55 Pa. Code §  1101.43 (relating to enrollment and ownership reporting requirements); 55 Pa. Code §  1127.71 (relating to scope of claims review procedures); 55 Pa. Code §  1128.71 (relating to scope of claims review procedures); 55 Pa. Code §  1181.542 (relating to who is required to be screened); 55 Pa. Code Chapter 1181 Appendix O (relating to OBRA sanctions); and 55 Pa. Code §  5221.43 (relating to quality assurance and utilization review).



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