Bureau of Hearings and Appeals Non-Formal Provider Appeals

Medical providers or other persons or agencies that are not applicants or recipients of welfare benefits file non-recipient appeals. Types of non-recipient appeals include appeals from medical assistance providers (Diagnosis Related Group, Concurrent Hospital Review and Retrospective Inpatient Provider Denial), and mental health and mental retardation liability appeals. Typically, the issue under appeal for provider appeals is denial of payment for services rendered. Denials are made for various reasons ranging from improper billing procedures to administration of medically unnecessary services. These hearings are governed by 1 Pa. Code, Chapters 30, 33, & 35.

Regulations:

1 Pa. Code
55 Pa. Code Chapter 41