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Provider misutilization and abuse - 55 Pa. Code § 1101.73

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If the department of public welfare’s routine utilization review procedures indicate that a provider participating in the medical assistance program has been billing for services that are inconsistent with medical assistance regulations, unnecessary, inappropriate to patient’s health needs or contrary to customary standards of practice, payment on the provider’s invoices will be delayed or suspended for up to 120 days pending a review of his billing and services patterns.  The provider’s medical and/or fiscal records may be reviewed.

Current as of June 2015