55 Pa. Code § 1229.71 - Scope of claims review procedures
(a) Claims submitted for payment under the
Medical Assistance Program are subject to the utilization control procedures
established in Chapter 1101 (relating to general provisions). Providers shall
fully cooperate with audits and reviews made by the Department for the purpose
of determining the validity of claims, the reasonableness and necessity of
services provided and charges made to the general public.
(b) The Health Maintenance Organization (HMO)
contractor shall cooperate fully with the Office of Medical Assistance or its
authorized agents in exercising the responsibility of the Department to conduct
periodic medical audits under Federal regulations at 42 CFR
431.543.
Notes
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