Medical providers or other persons or agencies that are not applicants or recipients of welfare benefits file non-formal (expedited) appeals. Types of non-formal (expedited) 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.
Appeals filed by medical assistance providers follow special regulations. Medical assistance provider appeals filed after 11/24/06 are governed by the regulations found at 55 Pa. Code Chapter 41.
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.
Non-formal (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.
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.