1. (a) Invoices. When billing for MA services or items, a provider shall use the invoices specified by the Department or its agents, according to billing and other instructions contained in the provider handbooks.

2. (b) Time frame. MA providers shall submit invoices correctly and in accordance with established time frames. For purposes of this section, time frames referred to are indicated in calendar days.

   1. (1) A provider shall submit original or initial invoices to be received by the Department within a maximum of 180 days after the date the services were rendered or compensable items provided. Nursing facility providers and ICF/MR providers shall submit original or initial claims to be received by the Department within 180 days of the last day of a billing period. A billing period for nursing facility providers and ICF/MR providers covers the services provided to an eligible recipient during a calendar month and starts on the first day service is provided in that calendar month and ends on the last day service is provided in that calendar month.
   2. (2) Departmental receipt of a claim is evidenced by appearance of the claim on a remittance advice (RA). The claim reference number (CRN) identifies when the claim was received by the Department. The first digit of the CRN indicates the year. The next three digits refer to the Julian Calendar date.
   3. (3) Resubmission of a rejected original claim or a claim adjustment shall be received by the Department within 365 days of the date of service, except for nursing facility providers and ICF/MR providers. Resubmission of a rejected original claim or claim adjustment by a nursing facility provider or an ICF/MR provider shall be received by the Department within 365 days of the last day of each billing period.
   4. (4) A claim which has been submitted to the Department not appearing within 45 days following that submission, should be resubmitted by the provider. Similarly, a claim which appears as a pend on a remittance advice and does not subsequently appear as an approved or rejected claim before the expiration of an additional45 days should be resubmitted immediately by the provider.

3. (c) Invoice exception criteria. Invoices submitted after the 180-day period will be rejected unless they meet the criteria established in paragraph (1) or (2).

   1. (1) Eligibility determination was requested within 60 days of the date of service and the Department has received an invoice exception request from the provider within 60 days of receipt of the eligibility determination.
   2. (2) Payment from a third party was requested within 60 days of the date of service and the Department has received an invoice exception request from the provider within 60 days of receipt of the statement from the third party.

4. (d) Other invoice exception requirements. In addition to the requirements in subsection (c), the following requirements apply:

   1. (1) A provider shall submit invoice exception requests in writing to the Office of Medical Assistance Programs.
   2. (2) A request for an invoice exception shall include supporting documentation, including documentation to and from the CAO or third party. A correctly completed invoice shall accompany the request.
   3. (3) The Department may request additional documentation to justify approval of an exception. If the requested documentation is not received within 30 days from the date of the Department’s request, a decision will be made based on available information.
   4. (4) Invoice exceptions will be granted on a one time basis. Exception claims rejected through the claims processing system due to provider error will not be granted additional exceptions. Claims may be resubmitted directly to the claims processing system in accordance withsubsection (b). The claim shall indicate the CRN of the exception claim on the invoice.
   5. (5) No exceptions to the normal invoice processing deadlines will be granted other than under this section. In addition, if a provider’s claim to the Department incurs a delay due to a third party or an eligibility determination, and the 180-day time frame has not elapsed, the provider shall still submit the claim through the normal claims processing system. A request for an exception to the 180-day time frame is not required whenever the provider can submit the claim within that 180-day period.
   6. (6) No exceptions will be granted for claims which were submitted for normal processing within normal deadlines and rejected by the Department due to provider error.

Authority

This section amended under Articles I—XI and XIV of the Human Services Code (62 P.S. § § 101—1411).

Source

The provisions of this § 1101.68 amended December 14, 1990, effective January 1, 1991, 20 Pa.B. 6164; amended December 27, 2002, effective January 1, 2003, 32 Pa.B. 6364. Immediately preceding text appears at serial pages (290141) to (290143).

Notes of Decisions

Conformity with Federal Law

The time constraints in § 1101.68 for providers to submit claims are wholly in conformity with Federal law. Presbyterian Medical Center of Oakmont v. Department of Public Welfare, 792 A.2d 23 (Pa. Cmwlth. 2002).

Agency Interpretation

Because the Federal government has approved the Commonwealth’s Medical Assistance State Plan, the court is obligated to grant great deference to that plan, as well as to the Department’s interpretation of its own regulations. Presbyterian Medical Center of Oakmont v. Department of Public Welfare, 792 A.2d 23 (Pa. Cmwlth. 2002).

Denial Not a Forfeiture

The denial of a claim for failure to comply with the properly enacted time constraints is not a forfeiture. The denial of the claim was not an arbitrary act, but was based upon duly enacted regulations that are reasonable and provide ample time for submission of a claim. There is no basis in logic or law—constitutional or otherwise—to conclude that the denial is a forfeiture. Presbyterian Medical Center of Oakmont v. Department of Public Welfare, 792 A.2d 23 (Pa. Cmwlth. 2002); appeal denied 839 A.2d 354 (Pa. 2003).

De Novo Hearing

The failure of the administrative hearing officer to provide a full evidentiary, de novo hearing from a denial of an application for a Medical Assistance Provider Agreement constitutes reversible error. Millcreek Manor v. Department of Public Welfare, 796 A.2d 1020 (Pa. Cmwlth. 2002).

Invoice Exception

The 60-day time periods set forth at 55 Pa. Code § 1101.68(c)(1) are considered satisfied if, for services provided during an entire month, the last day of service in that month falls within the 60-day period. Ashton Hall, Inc. v. Department of Public Welfare, 743 A.2d 529 (Pa. Cmwlth. 1999).

Because the request for an eligibility determination was made on June 12, which was more than 60 days after the last day of March, the nursing facility’s exception request was not timely submitted and the Department properly denied it. Ashton Hall, Inc. v. Department of Public Welfare, 743 A.2d 529 (Pa. Cmwlth. 1999).

Because strict compliance with the requirements of duly promulgated regulations is mandatory, the doctrine of substantial performance was inapplicable and could not excuse the nursing facility’s failure to submit an exception request within the 60-day period specified in the regulation. Ashton Hall, Inc. v. Department of Public Welfare, 743 A.2d 529 (Pa. Cmwlth. 1999).

Since failure of Medical Assistance provider to submit invoices for payment within the 6-month period as required by subsection (a) was due to extreme negligence of an employe rather than the result of a technical or inadvertent omission, the equitable doctrine of substantial performance could not be invoked to require payment. State College Manor Ltd. v. Department of Public Welfare, 498 A.2d 996 (Pa. Cmwlth. 1985).

The strict 6 month deadline for submission of invoices by Medical Assistance providers is not arbitrary or unreasonable since it was intended and does benefit providers by assuring prompt payment. State College Manor Ltd. v. Department of Public Welfare, 498 A.2d 996 (Pa. Cmwlth. 1985).

Question of the proper interpretation of the 180-day rule under this provision was not reached by the court, where the fact-finder, the director of the Office of Hearing and Appeals of the Department, made a finding of fact concerning the submission of invoices so vague as to be insufficient to resolve the complex questions in the case. Allied Services for Handicapped, Inc. v. Department of Public Welfare, 528 A.2d 702 (Pa. Cmwlth. 1987).

The exceptions found in this section are intended to prevent payment denial because of circumstances beyond the provider’s control. Nayak v. Department of Public Welfare, 529 A.2d 557 (Pa. Cmwlth. 1987).

Regulations are not Contract Terms

Section 1101.68 is not a contract term. Therefore, strict compliance is mandatory and substantial compliance is insufficient. Presbyterian Medical Center of Oakmont v. Department of Public Welfare, 792 A.2d 23 (Pa. Cmwlth. 2002); appeal denied 839 A.3d 354 (Pa. 2003).

Validity; Effect

A regulation such as § 1101.68 (relating to invoicing for services), which was duly promulgated under legislative authority, has the force and effect of law if it is within the granted power, is issued pursuant to proper procedure and is reasonable. If so, it enjoys the presumption of validity and bears a heavy burden to overcome that presumption. Presbyterian Medical Center of Oakmont v. Department of Public Welfare, 792 A.2d 23 (Pa. Cmwlth. 2002); appeal denied 839 A.2d 354 (Pa. 2003).

Cross References

This section cited in 55 Pa. Code § 41.92 (relating to expedited disposition procedure for certain appeals); 55 Pa. Code § 52.14 (relating to ongoing responsibilities of providers); 55 Pa. Code § 52.41 (relating to provider billing); 55 Pa. Code § 1187.155 (relating to exceptional DME grants—payment conditions and limitations); and 55 Pa. Code § 6100.483 (relating to provider billing).