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A06085
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
2350
Session of
2020
INTRODUCED BY KAUFER, GROVE, GAYDOS, OWLETT, SANKEY, THOMAS,
JONES, MILLARD, BERNSTINE, RYAN, WHEELAND, SAYLOR, COX, MOUL,
KEEFER, KLUNK, DUSH, B. MILLER AND RADER, APRIL 3, 2020
REFERRED TO COMMITTEE ON HUMAN SERVICES, APRIL 3, 2020
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," in fraud and abuse
control, further providing for definitions, for restrictions
on provider charges and payments and for venue and
limitations on actions.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The definitions of "provider" and "recipient" in
section 1401 of the act of June 13, 1967 (P.L.31, No.21), known
as the Human Services Code, are amended and the section is
amended by adding definitions to read:
Section 1401. Definitions.--The following words and phrases
when used in this article shall have, unless the context clearly
indicates otherwise, the meanings given to them in this section:
"Claim" means a request for payment under the medical
assistance program.
* * *
"National Provider Identifier" or "NPI" means the national
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unique health identifier issued to a health care provider under
45 CFR Pt. 162 Subpt. D (relating to standard unique health
identifier for health care providers).
"Person" means any individual, facility or entity.
* * *
"Provider" means any individual [or], medical facility or
entity which [signs an agreement with the department to
participate in the medical assistance program, including, but
not limited to, licensed practitioners, pharmacies, hospitals,
nursing homes, clinics, home health agencies and medical
purveyors.] provides goods or services reimbursable under the
medical assistance program. signs an agreement with the
department to provide goods or services reimbursable under the
medical assistance program.
* * *
"Recipient" means an [eligible person who receives medical
assistance from a participating provider.] individual who
receives goods or services from a provider reimbursable under
the medical assistance program.
"Record" means any of the following:
(1) Any document in written, electronic or any other format
retained by a provider under the medical assistance program,
including, but not limited to, medical, professional, financial
or business documents which relate to:
(i) the treatment or care of a recipient;
(ii) goods or services provided to a recipient; or
(iii) rates paid for goods or services provided to a
recipient.
(2) Any document in written, electronic or any other format
that is required by the rules or regulations of the department
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to be retained by a provider under the medical assistance
program.
* * *
"State Provider Identifier" or "SPI" means a unique health
identifier issued to a provider by the department.
Section 2. Section 1406 of the act is amended by adding
subsections to read:
Section 1406. Restrictions on Provider Charges and
Payments.--* * *
(c) An individual A provider seeking to provide goods or
services reimbursable, in whole or in part, under the medical
assistance program who does not have a National Provider
Identifier shall register with the department and obtain a State
Provider Identifier prior to the provision of goods or services.
Each claim submitted to the department or an entity contracted
with the department under the medical assistance program must
include the NPI or SPI of the individual providing the goods or
services.
(d) The department shall create and implement a standardized
training program for individuals providing goods or services for
which a claim will be submitted using an SPI. An individual must
enroll in the standardized training at the time of application
for an SPI. The standardized training must be successfully
completed prior to the individual providing goods or services
reimbursable under the medical assistance program. The
standardized training shall:
(1) be specific to the type of goods or services to be
provided;
(2) focus on the required level of care to be provided;
(3) indicate the goods or services to be provided that may
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be properly claimed for reimbursement;
(4) provide contact information for the agency which is the
local provider of protective services; and
(5) provide information on procedures for reporting
suspected fraud relating to the medical assistance program.
(e) (1) All claims submitted, whether to the department or
any entity contracted with the department under the medical
assistance program, must include the following:
(i) the NPI or SPI issued to the individual delivering the
goods or services to the recipient;
(ii) the Medicaid provider number for the provider;
(iii) each date goods or services were provided; and
(iv) the start and end time for each service provided.
(2) The requirements of paragraph (1)(i) and (iv) do not
apply to per diem claims.
Section 3. Section 1411 of the act is amended to read:
Section 1411. Venue and Limitations on Actions.--(a) Any
civil actions or criminal prosecutions brought pursuant to this
act for violations hereof shall be commenced within five years
[of] after the date the violation or violations occur. [In
addition, any such actions or prosecutions may be brought in any
county where the offender has an office or place of business or
where claims and payments are processed by the Commonwealth or
where authorized by the Rules of the Pennsylvania Supreme
Court.]
(b) A civil action or criminal prosecution brought under
this act may be brought in any of the following:
(1) A county where the alleged offender has an office or
place of business.
(2) A county where claims or payments are processed by the
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Commonwealth or the Commonwealth's contractor or a
subcontractor.
(3) The county in which the records are submitted.
(4) The county where the goods or services are alleged to
have been provided.
(5) Any county authorized by the Pennsylvania Rules of
Criminal Procedures or other applicable rule of court for the
conduct of civil actions on criminal prosecutions.
Section 4. The department shall promulgate rules and
regulations necessary to implement the provisions of this act in
a manner which:
(1) Does not interrupt the provision of care to
recipients enrolled under the medical assistance program.
(2) Provides a reasonable amount of time for current
providers participating in the medical assistance program to
comply with the provisions of this act while still
participating in the program.
Section 5. This act shall take effect in 90 days.
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