PROVIDER PARTICIPATION

1. (a) In addition to the participation requirements established in Chapter 1101 (relating to general provisions), rural health clinics shall:

   1. (1) Participate in the Medicare Program.
   2. (2) Sign a provider agreement with the Department.
   3. (3) Have an established fee schedule for billing third party and private payors.

2. (b) The rural health clinic shall submit a letter of application to the Bureau of Provider Relations, Office of Medical Assistance, Park Penn Building, Post Office Box 8029, Harrisburg, Pennsylvania, that includes:

   1. (1) The name and address of the clinic.
   2. (2) A list of the clinic owners and officers or members of the board of directors.
   3. (3) The name and address of the physicians responsible for providing medical direction or supervision for the clinic.
   4. (4) A list of rural health clinic personnel providing medical services, their days and hours of coverage per week and month.
   5. (5) A description of the patient referral system.
   6. (6) Copies of contracts or agreements between the clinic and licensed practitioners of all types relating to services provided by the clinic.
   7. (7) A copy of the fee schedule used to charge private patients and third party payors.
   8. (8) A statement indicating which practitioners, if any, are salaried by the rural health clinic to provide services outside the clinic.
   9. (9) A copy of the cost report submitted to Medicare and a copy of the current or proposed budget or both.

Source

The provisions of this § 1129.41 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4597.