Subchapter J. NURSING FACILITY RIGHT OF APPEAL
1187.141. Nursing facilitys right to appeal and to a hearing.
§ 1187.141. Nursing facilitys right to appeal and to a hearing.
(a) A nursing facility has a right to appeal and have a hearing if the nursing facility does not agree with the Departments decision regarding:
(1) The peer group prices established annually by the Department for the peer group in which the nursing facility is included. The nursing facility may appeal the peer group prices only as to the issue of whether the peer group prices were calculated in accordance with § 1187.96 (relating to price and rate setting computations).
(i) A nursing facility may not challenge the validity or accuracy of any adjustment (except as provided in § 1187.141(10)) or any desk or field audit findings relating to the database or total facility CMIs used by the Department in calculating the peer group prices as a basis for its appeal of the peer group prices.
(ii) If more than one nursing facility in a peer group appeals the peer group prices established by the Department, the Office of Hearings and Appeals may consolidate for hearing the appeals relating to each peer group.
(2) The findings issued by the Department in a desk or field audit of the nursing facilitys MA-11 cost report.
(3) The Departments denial, nonrenewal or termination of the nursing facilitys MA provider agreement.
(4) The MA CMI established quarterly by the Department for the facility.
(5) The Departments imposition of sanctions or fines on the nursing facility under Subchapter I (relating to enforcement of compliance for nursing facilities with deficiencies).
(6) The total facility CMI established annually by the Department for the nursing facility.
(7) The rate established annually by the Department for the nursing facility for resident care cost, other resident related cost, administrative cost and capital cost.
(8) The quarterly adjustment made by the Department to the nursing facilitys rate based upon the facilitys MA CMI. The facility may appeal the quarterly rate adjustment only as to the issue of whether the quarterly rate adjustment was calculated correctly.
(9) The disproportionate share incentive payment made annually by the Department to the nursing facility. A nursing facility may appeal its disproportionate share incentive payment only as to the issue of whether the Department used the correct number of MA days of care and the correct inflation factor in calculating the facilitys payment.
(10) A retrospective gross adjustment made under § 1187.108 (relating to gross adjustments to nursing facility payments), for the peer group in which the nursing facility is included. The nursing facility may appeal the gross adjustment only as to the issue of whether the adjustment was calculated in accordance with a final administrative action or court order.
(i) A nursing facility may not challenge the validity or accuracy of the underlying action or order which resulted in the retrospective gross adjustment.
(ii) If more than one nursing facility in a peer group appeals a retrospective gross adjustment, the Office of Hearings and Appeals may consolidate for hearing the appeals relating to each peer group.
(b) A nursing facility appeal is subject to § 1101.84 (relating to provider right of appeal).
(c) A nursing facilitys appeal shall be filed within the following time limits:
(1) A nursing facilitys appeal of the peer group prices shall be filed within 30 days of the date on which the Department publishes the peer group price in the Pennsylvania Bulletin.
(2) A nursing facilitys appeal of the decisions listed in subsection (a)(2)(10) shall be filed within 30 days of the date of the Departments letter transmitting or notifying the facility of the decision.
(d) A nursing facilitys appeal shall meet the following requirements:
(1) A nursing facilitys appeal shall be in writing, shall identify the decision appealed and, in appeals involving decisions identified in subsection (a)(2)(10), shall enclose a copy of the Departments letter transmitting or notifying the nursing facility of the decision.
(2) A nursing facilitys appeal shall state in detail the reasons why the facility believes the decision is factually or legally erroneous and the specific issues that the facility will raise in its appeal, including issues relating to the validity of Department regulations. In addition, a nursing facility appeal of findings in a desk or field audit report shall identify the specific findings that the facility believes are erroneous and the reasons why the findings are erroneous. Reasons and issues not stated in a nursing facilitys appeal shall be deemed waived and will not be considered in the appeal or any subsequent related appeal, action or proceeding involving the same decision. Desk or field audit findings not identified in a nursing facility appeal will be deemed final and will not be subject to challenge in the appeal or any subsequent related appeal, action or proceeding involving the same desk or field audit.
(3) A nursing facility may amend its appeal in order to meet the requirements of paragraph (2). A nursing facility shall file its amended appeal within 90 days of the date of the decision appealed. An amended appeal shall be permitted only if the nursing facilitys appeal was filed in accordance with the time limits set forth in subsection (c). No subsequent amendment of an appeal will be permitted except under § 1187.1(d) (relating to policy).
(e) An appeal or an amended appeal shall be mailed to the Executive Director, Office of Hearings and Appeals, Department of Human Services, Post Office Box 2675, Harrisburg, Pennsylvania 17105. The date of filing is the date of receipt of the appeal or amended appeal by the Office of Hearings and Appeals.
(f) The Department may reopen an audit or a prior years audit if an appeal is filed.
This section cited in 55 Pa. Code § 41.3 (relating to definitions); 55 Pa. Code § 1187.75 (relating to final reporting); 55 Pa. Code § 1187.113b (relating to capital cost reimbursement waiversstatement of policy); 55 Pa. Code § 1187.115 (relating to adjustments relating to errors and corrections of nursing facility payments); and 55 Pa. Code § 1187.158 (relating to appeals).
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