Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 7346 (November 25, 2023).

55 Pa. Code § 41.92. Expedited disposition procedure for certain appeals.

§ 41.92. Expedited disposition procedure for certain appeals.

 (a)  This section applies to provider appeals involving the denial of claims for payment through the prior authorization process, the denial of requests for precertification, the recovery of overpayments or improper payments through the utilization review process, the denial of claims upon prepayment review, the denial of claims for payment under §  1101.68 (relating to invoicing for services), the denial, termination or suspension of an exceptional DME grant as defined in §  1187.2 (relating to definitions) and the denial of a program exception request filed under §  1150.63 (relating to waivers).

 (b)  A request for hearing in a provider appeal subject to this section shall be submitted in writing to the Bureau within the time limits specified in accordance with §  41.32(a) (relating to timeliness and perfection of requests for hearing) and include both of the following:

   (1)  The information specified in §  41.31(d) (relating to request for hearing).

   (2)  Relevant supporting documentation.

 (c)  The provider shall send a copy of its request for hearing to the program office issuing the notice of the agency action at the same time it files its request with the Bureau.

 (d)  Unless the information has already been exchanged, each party shall give to the other parties a document that it will introduce as an exhibit and a list of the persons, including medical or other experts, which it will call as a witness at the hearing.

 (e)  The Bureau will promptly schedule a hearing taking into due consideration the availability of expert witnesses. The Bureau will provide at least 3 weeks notice of a hearing from the date of notice.

 (f)  The following sections of this chapter do not apply to appeals subject to this section:

   (1)  Section 41.11 (relating to title of document).

   (2)  Section 41.12 (relating to form).

   (3)  Section 41.14 (relating to verification).

   (4)  Section 41.22(1)(ii) (relating to service of pleadings and legal documents).

   (5)  Section 41.23 (relating to proof of service).

   (6)  Sectin 41.24 (relating to certificate of service).

   (7)  Section 41.101 (relating to prehearing procedure in certain provider appeals).

   (8)  Sections 41.111—41.123.

   (9)  Section 41.134 (relating to discovery motions).

   (10)  Section 41.135 (relating to dispositive motions), except for a motion to dismiss based upon timeliness.

   (11)  Section 41.141 (relating to voluntary mediation).

   (12)  Section 41.151 (relating to initiation of hearings).

   (13)  Section 41.181 (relating to posthearing briefs).

 (g)  Upon motion of a party, and for good cause shown, the Bureau may order that a provider appeal identified in subsection (a) be exempt from this section or may order that one or more of the sections identified in subsection (f) apply in whole or in part to the appeal. In the case of a motion seeking an order to apply § §  41.111—41.121 to a provider appeal identified in subsection (a), in order to show good cause, the moving party shall establish that the disclosures or discovery will not prevent the prompt and efficient adjudication of the appeal and are reasonable and necessary given the facts involved in the appeal.

 (h)  Upon joint motion of the parties to a provider appeal, the Bureau may order that this section applies to a provider appeal not identified in subsection (a).

 (i)  A motion to exempt an appeal from this section under subsection (g) and a joint motion to apply this section to an appeal under subsection (h) may be filed with the request for hearing, but shall be filed no later than 30 days from the filing date of the request for hearing in the provider appeal.



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