Formal Provider Appeals

Formal Medical Assistance Provider appeals are governed by the regulations at 55 Pa. Code, Chapter 41. These appeals include Provider appeals from audit determinations and preclusion orders by the Department of Human Services that preclude providers from participating in the Pennsylvania Medical Assistance program.

Hearings are normally held face-to-face with a stenographer present to record the proceedings. These hearings take on a true court-like atmosphere. The Formal Pre-Hearing Unit, operating in the Harrisburg Headquarters Office, is responsible for processing of these appeals and scheduling hearings for them.

The Formal Pre-Hearing Unit is responsible for the pre-hearing processing of all formal type appeals received by BHA. Pre-hearing processes include: pre-screening for adherence to state and federal filing requirements, docketing, data entry, scheduling and conducting telephonic pre-hearing conferences and possibly a timeliness hearing. If a full hearing on the merits is needed, the date of such a hearing may be determined during the pre-hearing conference. Formal notices of a hearing are sent to the parties regarding the date, time, and location of the hearing. The file and all accompanying documentation are forwarded to the appropriate region prior to the hearing date.

To determine if you have the right to appeal and/or if BHA has jurisdiction over the matter which you dispute, reference Pennsylvania regulations at www.pacode.com or www.pabulletin.com.

Medical Assistance Provider appeals are classified as formal appeals unless the regulations require, or the parties agree, that the appeal may be expedited. Expedited appeals forego many of the prehearing formalities required under the regulations and allow the appeal to be scheduled for a hearing in an expeditious manner. Expedited hearings are typically held by telephone.

You can search Bureau of Hearings and Appeals decisions on Medical Assistance provider appeals. Most of the documents listed in this search are in Portable Document Format (.pdf). If you have trouble accessing this information you may obtain an alternative format by contacting the Bureau of Hearings and Appeals (717-783-3950) and requesting a publication.

Standing Practice Order - Formal Appeals - Provides information and instruction regarding the pre-hearing procedures for matters that have been docketed as Formal Appeals before the Bureau of Hearings and Appeals. This document also contains a list of Legal Services Corporations.

Medical Assistance Provider Appeals (after 11/24/06) - Establishes rules governing practice and procedure in Medical Assistance provider appeals. Note: Any Medical Assistance Provider appeals filed between 7/1/03 and 11/24/06 would follow a Standing Practice Order. Please contact the Bureau of Hearings and Appeals for a copy.

55 Pa. Code Chapter 41
Procedure for Telephonic Testimony in Formal Cases
Unified Pre-Hearing Filing Instruction Sheet