Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1806 (March 30, 2024).

55 Pa. Code § 1126.82. Administrative sanctions.

§ 1126.82. Administrative sanctions.

 (a)  If the ASC/SPU quality assurance/utilization review committee fails to review a Medical Assistance recipient’s need for admission or fails to request approval for the admission through the Department’s Bureau of Policy and Program Development, the Department will deny payment for the stay.

 (b)  If the Department determines that a facility billed for services inconsistent with this chapter and Chapter 1101 (relating to general provisions), provided incorrect information on the billing invoice regarding a patient’s diagnosis or procedures performed, the Department will deny payment for the claims.

 (c)  If the Department determines that an ASC/SPU claim has been inappropriately coded based on information in the patient’s medical record or discovers coding errors, the Department will correct the claim for payment purposes.

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