Section 22.91. Applicant or claimant appeals

(a) Appealable actions. Applicants for, or claimants of, benefits provided under the PACE Program shall have the right to appeal the following adverse actions taken by the Department:

(1) The rejection of an application for enrollment in the PACE Program except as provided for in subsection (b)(1).

(2) The suspension or termination of a claimant’s enrollment and the benefits of enrollment in the program because of abuse or misuse of the program.

(3) The disallowance of, and actions to recover, costs related to claimant abuse or misuse of the program benefits.

(4) Other adverse actions of the Department except those which are indicated in subsection (b).

(b) Nonappealable actions. Applicants or claimants do not have the right to appeal the following actions:

(1) Rejection of an application for enrollment or termination of benefits because the applicant has refused to submit requested documents or other information necessary to establish eligibility for enrollment.

(2) Rejection of an application for re-enrollment from a claimant whose enrollment has been suspended or terminated prior to the date on which the Department specified that re-enrollment would be considered.

(3) Disallowances for prescription drugs dispensed during a period of nonenrollment, supsension or termination of claimant benefits, except on the issue of identity.

The provisions of this § 22.91 adopted June 15, 1984, effective June 16, 1984, 14 Pa.B. 2109; amended December 14, 1990, effective December 15, 1990, 20 Pa.B. 6143. Immediately preceding text appears at serial pages (103141) to (103142).

Notation

Cross References

This section cited in 6 Pa. Code § 22.37 (relating to right of appeal); 6 Pa. Code § 22.46 (relating to right of appeal); and 6 Pa. Code § 22.74 (relating to claimant right of appeal).