Section 6210.121. Decisions that may be appealed

(a) The facility has a right to appeal and have a hearing if dissatisfied with the Department’s decision regarding:

(1) The interim per diem rate established by the Department.

(2) The findings of the auditors in the annual audit report.

(3) The determination by the comptroller of the difference between the allowable costs certified by the auditors in the annual audit report, and the total allowance amount as shown on the interim billing.

(4) The denial or nonrenewal of a provider agreement.

(b) Facilities participating in Medicare and the MA Program that are denied renewal of a MA Provider Agreement or have the Agreement terminated by the Department because of termination or nonrenewal by Medicare are entitled to the review procedures specified for Medicare facilities at 42 CFR Part 498 (relating to appeals procedures for determinations that affect participation in the Medicare Program). The final decision entered as a result of the Medicare review procedures is binding for the purposes of participation in the MA Program.

Notation

Notes of Decisions

Appeal

Health care provider that provided care and services to persons with mental retardation have an administrative remedy that could address its claims that Department of Public Welfare failed to reimburse it on cost-related basis for direct care staff costs, and reimbursed State-operated facilities more than non-State providers for same services; therefore, it must first pursue that avenue of relief before seeking judicial review. Network v. Department of Public Welfare, 833 A.2d 271, 275 (Pa. Cmwlth. 2003)

Cross References

This section cited in 55 Pa. Code § 6210.94 (relating to auditing requirements related to recipient fund management); and 55 Pa. Code § 6210.123 (relating to time limit for submission of appeal).