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Medicaid/CHIP Data Requirements in Pennsylvania

        Individuals enrolled in Pennsylvania’s medical assistance programs may obtain services from any institution, agency, pharmacy, or organization that tis approved by the Department of Public Welfare to provide such services; providers are prohibited from denying the services or discriminating against medical assistance patients on the grounds of race, color, national origin or handicap.1  Moreover, every practitioner must adhere to basic standards of practice, included maintaining a proper record for each patient that contains a complete medical history of the patient, all treatment plans, results of any interventions, as well as other critical information.2  The patient record should also include certain demographic and personal identification information, such as the patient’s full name and address, and dates of all visits.3

        Various types of practices within the state may have additional record keeping and cost reporting requirements under the medical assistance program, including outpatient psychiatric clinics4, inpatient psychiatric facilities5, nursing facilities6, pharmacies7, shared health facilities8, and hospitals.9  Regardless of practice type, all providers must retain copies of all financial records to fully support claims and charges for payment under the medical assistance program for at least four years.10

 

Footnotes

  • 1. 55 Pa. Code § 1101.51 (2012)
  • 2. 55 Pa. Code § 1101.51 (2012)
  • 3. 62 Pa. Stat. Ann. § 1403 (West 2012)
  • 4. 55 Pa. Code § 1153.42 (2012)
  • 5. 55 Pa. Code § 1151.47 (2012)
  • 6. 55 Pa. Code § 1181.64 (2012)
  • 7. 55 Pa. Code, Chapter 1121 (2012)
  • 8. 55 Pa. Code § 1102.34 (2012)
  • 9. 55 Pa. Code § 1163.64 (2012)
  • 10. 62 Pa. Stat. Ann. § 1402 (West 2012)

 

Medicaid/CHIP Data Requirements in Pennsylvania

Subtopic Statute/Regulation Description
Medicaid/CHIP Data Requirements Annual audited financial statements - 28 Pa. Code § 912.61 Hospitals and ambulatory service facilities must annually file audited and certified financial statements within 120 days after the close of the...
Annual cost reporting - 55 Pa. Code § 1151.47 Inpatient psychiatric facilities must complete form MA 336 (Financial Report for Hospital and Hospital-Health Care Complex Under the Medical...
Cost reporting - 55 Pa. Code § 1181.64 Each nursing facility must submit a cost report to the department of welfare within 90 days of the close of each fiscal year.  The cost report...
Cost reporting - 55 Pa. Code § 1187.71 Nursing facilities must report costs to the medical assistance program by filing an acceptable MA-11 with the department of welfare, which includes...
Cost reports - 55 Pa. Code § 1163.64 Hospitals must complete form MA 336 (Financial Report for Hospital and Hospital-Health Care Complex Under the Medical Assistance Program of the...
Medicare cost reports and Medical Assistance Form 336 - 28 Pa. Code § 912.63 Hospitals and ambulatory care facilities must quarterly report summary utilization and financial reports to the council. 28 Pa. Code Chapter 912,...
Ongoing responsibilities of providers - 55 Pa. Code § 1121.42 As a condition of participation in the medical assistance program, pharmacies must permit authorized officials to conduct onsite reviews for the...
Ongoing responsibilities of providers - 55 Pa. Code § 1153.42 Outpatient psychiatric clinics and outpatient psychiatric partial hospitalization facilities must include the following information in the medical...
Ongoing responsibilities of providers- 55 Pa. Code § 1101.51 Recipients of medical assistance may obtain services from any institution, agency, pharmacy, person or organization that is approved by the...
Participation requirements - 55 Pa. Code § 1140.41 The Healthy Beginnings PLUS Program (HBP) is a comprehensive package of prenatal and postpartum services provided to eligible medical assistance...
Payment conditions for various services - 55 Pa. Code § 1121.52 Medical assistance prescriptions must contain the following information on the prescription form:1         The...
Provider fraud - 55 Pa. Code § 1101.4 If the department of public welfare determines after an investigation that a provider participating in the medical assistance program has submitted...
Provider misutilization and abuse - 55 Pa. Code § 1101.73 If the department of public welfare’s routine utilization review procedures indicate that a provider participating in the medical assistance...
Recipient misutilization and abuse - 55 Pa. Code § 1101.91 Providers must notify the local County Assistance Office if he has reason to believe that a recipient is mis-utilizing or abusing medical assistance...
Required data elements - 28 Pa. Code § 912.21 Health care facilities must quarterly submit the following data elements:1         Those contained in health...
Responsibilities relating to provider performance - 55 Pa. Code § 1102.34 The operator of a shared health facility must insure that providers rendering services to recipients at the facility and persons employed by the...
Responsibilities relating to the provision of medical services - 55 Pa. Code § 1102.33 The operator of a registered shared health facility must do the following: Insure that a recipient is treated by a practitioner who is familiar...
Scope of claims review procedures - 55 Pa. Code § 1121.71 Claims submitted by pharmacies under the medical assistance program are subject to utilization review. 55 Pa. Code Chapter 1121, “Scope of...
Special participation requirements for shared health facilities - 62 Pa. Stat. Ann. § 1403 The minimum care requirements for a shared health facility are as follows: Maintain proper recipient records which contain the following...
Special Provider Participation Requirements - 62 Pa. Stat. Ann. § 1402 As a condition of participation in the medical assistance program, a provider must maintain appropriate medical and financial records to fully...
Utilization control - 6 Pa. Code § 22.81 Providers enrolled in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE) Program must provide the following information:...