Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 2336 (April 27, 2024).

Pennsylvania Code



52.61.    Provider cessation of services.
52.62.    Prohibition of services.
52.63.    Provider misutilization and abuse.
52.64.    Payment sanctions.
52.65.    Appeals.

§ 52.61. Provider cessation of services.

 (a)  If a provider is no longer able or willing to provide services, the provider shall perform the following:

   (1)  Send written notification to each participant, the Department and other providers with which the provider works that the provider is ceasing services at least 30 days prior to the provider ceasing services.

   (2)  Notify licensing or certifying entities as required.

   (3)  Send the Department a copy of the notification sent to a participant and service providers as required under paragraph (1). If the provider uses a general notification for all participants or service providers, a single copy of the notification is acceptable.

   (4)  Cooperate with the Department, new providers of services and participants with transition planning to ensure the participant’s continuity of care.

 (b)  If the provider fails to notify the Department as specified in subsection (a), the provider shall forfeit payment for each day that the notice is overdue until the notice is issued.

§ 52.62. Prohibition of services.

 (a)  A provider may be sanctioned, prohibited or disenrolled from providing services for failure to perform any of the following:

   (1)  Protect the health and welfare of a participant during service delivery.

   (2)  Comply with applicable Federal or State laws and this chapter.

   (3)  Comply with a provision of the MA provider agreement, including the waiver addendum.

   (4)  Deliver a service in the type, scope, amount, duration and frequency required by the approved service plan when the participant is available for the delivery of the service.

   (5)  Develop or implement a CAP.

   (6)  Maintain licenses or certifications, or both, as required by Federal or State agencies.

   (7)  Maintain accurate records.

 (b)  The Department may prohibit a provider from providing new participants with services if the provider violates subsection (a).

 (c)  A disenrolled provider shall cooperate with the Department, new providers of services and participants with transition planning to ensure participant’s continuity of care.

§ 52.63. Provider misutilization and abuse.

 (a)  If the Department’s audit, financial review or monitoring indicates that a provider has been billing for services in a manner inconsistent with this chapter, unnecessary or inappropriate to a participant’s needs, or contrary to customary standards of practice, the Department will notify the provider in writing that payment on all invoices will be delayed or suspended for a period not to exceed 120 days pending a review of billing and service patterns.

 (b)  A provider may have its invoices reviewed prior to payment.

 (c)  A provider’s records may be reviewed.

 (d)  A provider may be required to submit a written explanation of billing practices.

§ 52.64. Payment sanctions.

 (a)  If the provider fails to submit an acceptable attestation engagement or pass a financial review, in accordance with this chapter, the Department may initiate sanctions against the provider including the following:

   (1)  Disallowing all or a portion of a payment.

   (2)  Suspending a current or future payment pending compliance.

   (3)  Recouping a payment for a service the provider cannot verify as being provided in the amount, duration and frequency billed.

 (b)  If a provider does not comply with this chapter or other State or Federal requirements, the Department may initiate the sanctions under subsection (a).

§ 52.65. Appeals.

 A provider may file an appeal of a Departmental action in accordance Chapters 41 and 1101 (relating to Medical Assistance provider appeal procedures; and general provisions).

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