Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › FACILITY RIGHT TO APPEAL › Section 1181.101 - Facility's right to a hearing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A nursing facility has a right to appeal
					 and have a hearing if dissatisfied with the Department's decision regarding:
(1) The interim per diem rate established by
					 the Department, unless a change in the interim per diem rate is made by the
					 Department based on a revision to the net operating portion of the rate as a
					 result of a revision to the applicable net operating cost reimbursement
					 ceiling, in which case the facility may appeal only as to the issue of whether
					 or not the ceiling used to revise the interim per diem rate is in fact the
					 established ceiling for the facility's geographical grouping and level of
					 care.
(2) The findings of the
					 auditors in the annual audit report.
(3) The determination by the comptroller of
					 the difference between the allowable costs certified by the auditors in the
					 annual audit report, and the total allowance amount as shown on the interim
					 billing.
(4) The denial or
					 nonrenewal of a provider agreement.
(i) A
					 skilled nursing facility that has been either denied an MA Provider Agreement
					 or renewal of the agreement or whose agreement has been terminated in whole or
					 in part by the Department prior to its expiration date, has the right to a full
					 evidentiary hearing before a hearing officer to contest the action.
(ii) Facilities participating in Medicare and
					 the MA Program that are denied renewal of an MA Provider Agreement or have the
					 agreement terminated by the Department because of termination or nonrenewal by
					 Medicare are entitled to the review procedures specified for Medicare
					 facilities in 42 CFR Part 498 (relating to appeals procedures for
					 determinations that affect participation in the Medicare Program). The final
					 decision entered as a result of the Medicare review procedures is binding for
					 the purposes of participation in the MA Program.
(5) The MA Program enhancement payment
					 consisting of the 2% inflation adjustment of the interim rate or interim cost
					 settlement made by the Department for Fiscal Years 1992-1993, 1993-1994 and
					 1994-1995.
(i) The facility's right to appeal
					 shall be limited to the issue of whether:
(A)
					 Its MA Program enhancement payment consisting of 2% inflation adjustment of the
					 facility's interim rate was calculated in accordance with §§
														1181.67(1) and
					 1181.211 (relating to setting
					 interim per diem rates; and cost reimbursement principles and
					 method).
(B) Its interim cost
					 settlement was calculated in accordance with §
														1181.69(c)
					 (relating to annual adjustment).
(ii) This paragraph does not otherwise limit
					 a facility's right to file an appeal under §
													1101.84 (relating to provider
					 right of appeal) or this section from interim rates established under §
													1181.221 (relating to determining
					 the interim per diem rate) or established as a result of a revision to the
					 ceilings on net operating costs, or from audit findings or final cost
					 settlement issued with respect to which an interim cost settlement is
					 paid.
(6) The MA Program
					 enhancement payment consisting of the 2% inflation adjustment of the interim
					 rate made by the Department for the period July 1, 1995, through December 31,
					 1995. The nursing facility's right to appeal shall be limited to the issue of
					 whether its MA Program enhancement payment consisting of the 2% inflation
					 adjustment of the nursing facility's interim rate was calculated in accordance
					 with §§ 1181.67(1) and 1181.211.