1. (a) Providers reimbursed under the Medicare Part B Program shall submit the following documents with their application for fee review:

   1. (1) The applicable Medicare billing form.
   2. (2) The required medical report form, together with office notes and documentation supporting the procedures performed or services rendered.
   3. (3) The explanation of benefits, if available.

2. (b) Providers reimbursed under the Medicare Part A Program and providers reimbursed by Medicare based on HCFA Forms 2552, 2540, 2088 or 1728, or successor forms, shall submit the following documents with the application for fee review:

   1. (1) The applicable Medicare billing form.
   2. (2) The most recent Medicare interim rate notification.
   3. (3) The most recent Notice of Program Reimbursement.
   4. (4) The most recently audited Medicare cost report.
   5. (5) The required medical report form, together with documentation supporting the procedures performed or services rendered.
   6. (6) The explanation of benefits, if available.
3. (c) For treatment rendered on and after January 1, 1995, the items specified in subsections (b)(2)—(4) shall be submitted if the requirements of § 127.155 (relating to medical fee updates on and after January 1, 1995—outpatient acute care providers, specialty hospitals and other cost-reimbursed providers) have been met.

Cross References

This section cited in 34 Pa. Code § 127.252 (relating to application for fee review—filing and service).