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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 8238 (December 30, 2023).

55 Pa. Code § 1229.71. Scope of claims review procedures.


§ 1229.71. Scope of claims review procedures.

 (a)  Claims submitted for payment under the Medical Assistance Program are subject to the utilization control procedures established in Chapter 1101 (relating to general provisions). Providers shall fully cooperate with audits and reviews made by the Department for the purpose of determining the validity of claims, the reasonableness and necessity of services provided and charges made to the general public.

 (b)  The Health Maintenance Organization (HMO) contractor shall cooperate fully with the Office of Medical Assistance or its authorized agents in exercising the responsibility of the Department to conduct periodic medical audits under Federal regulations at 42 CFR 431.543.


   The provisions of this §  1229.71 adopted October 31, 1980, effective November 1, 1980, 10 Pa.B. 4255.

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