PROVIDER HEARINGS AND APPEALS

1. (a) Appealable actions. Providers shall have the right to appeal the following adverse actions taken by the Department:

   1. (1) The rejection of an application for enrollment in the PACE Program when the provider believes the rejection is based upon incorrect or incomplete information.
   2. (2) The termination of an enrolled provider’s agreement under § 22.84 (relating to administrative actions and penalties), except as provided for in subsection (b)(1).
   3. (3) The disallowance of payments to an enrolled provider where the Department has determined the payments are not valid because of provider error, negligence or abuse.
   4. (4) Other adverse actions of the Department except those which are indicated in subsection (b).

2. (b) Nonappealable actions. Providers do not have the right to appeal the following actions:

   1. (1) The termination of a provider agreement because of the provider’s termination or suspension from Medicare or Medical Assistance, or because of a conviction of a criminal offense under § 22.83 (relating to prohibited acts and criminal penalties), or because of a conviction of another criminal offense or disciplinary action indicated in § 22.84 except on the issues of identity or misinformation.
   2. (2) Disallowances for prescription drugs dispensed during a period of nonenrollment or termination, except on the issues of identity or misinformation.
   3. (3) Rejection of an application to reenroll a terminated or excluded provider prior to the date the Department specified that it would consider reenrollment.

Source

The provisions of this § 22.101 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 (96851) to (96852).

Cross References

This section cited in 6 Pa. Code § 22.62 (relating to conditions of provider participation); 6 Pa. Code § 22.85 (relating to re-enrollment of providers whose agreements have been terminated); and 6 Pa. Code § 22.86 (relating to provider right of appeal).