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SATISH R. NAYAK v. COMMONWEALTH PENNSYLVANIA (07/21/87)

decided: July 21, 1987.

SATISH R. NAYAK, M.D., PETITIONER
v.
COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF PUBLIC WELFARE, RESPONDENT



Appeal from the Order of the Department of Public Welfare, Office of Hearings and Appeals, in case of Appeal of: Satish R. Nayak, M.D., Case No. 56J0001, dated April 23, 1986.

COUNSEL

James F. O'Malley, with him, Margaret A. O'Malley, Yost & O'Malley, for petitioner.

Jason Manne, Assistant Counsel, with him, Mary Frances Grabowski, Assistant Counsel, and John Kane, Chief Counsel, for respondent.

Judges MacPhail and Colins, and Senior Judge Blatt, sitting as a panel of three. Opinion by Judge Colins.

Author: Colins

[ 107 Pa. Commw. Page 505]

Satish R. Nayak, M.D., an enrolled provider in the Pennsylvania Medical Assistance Program (MA Program),*fn1 appeals an order of the Department of Public Welfare (DPW), Office of Hearings and Appeals, which adopted the recommendation of the Hearing Officer denying his appeal from the refusal of his request for an exception to the time limitations imposed upon the submission of invoices for payment of health care services rendered.

The time limitations on submission of invoices at issue in this case are found at Section 1101.68 of the Medical Assistance Manual (MA Manual), 55 Pa. Code § 1101.68, effective January 1, 1980, as modified by the provisions of the Medical Assistance Bulletin (MA

[ 107 Pa. Commw. Page 506]

Bulletin) 99-83-05, issued on November 1, 1983. Section 1101.68 of the MA Manual states that:

(a) Providers shall use the invoices specified by the Department or its agents when billing for Medical Assistance services or items. Providers shall submit the invoices within 6 months after the delivery of the services or items. Invoices that have not been completed according to specified instructions or that lack any required documentation will be rejected by the Department. In the event that an invoice is rejected by the Department, a remittance advice will be sent to the provider explaining the reason for the rejection. The provider may submit a corrected invoice for payment.

(b) Invoices submitted after the 6-month period will be rejected absolutely unless:

(1) A recipient eligibility determination that was required to be made by a CAO [county assistance office] was delayed for 30 days or longer.

(2) Payment is being requested from a third party resource.

55 Pa. Code § 1101.68(a) and (b). (Emphasis added.)

Under the modified procedure defined by the MA Bulletin, original invoices must be submitted to DPW within 180 days of the date of service. All claims adjustments and resubmissions must be received by DPW within 365 days of the date of service. The procedure thereby affords the provider one year from the date of service to submit correct invoices for payment, regardless of the number of resubmissions.*fn2

[ 107 Pa. Commw. Page 507]

In the years 1983 and 1984, Dr. Nayak timely submitted claims to the MA Program for reimbursement of services rendered to ten patients*fn3 eligible under Medicaid. Without detailing the specific handling of each invoice, suffice it to say that each invoice was rejected by DPW and payment was denied for one of the following reasons: (1) the improper coding as to type and place of service; (2) the absence of a patient Medical Assistance (MA) identification number; and (3) the alleged availability of alternative third party insurance negating DPW's liability for payment. In most instances, Dr. Nayak attempted to correct the coded information and resubmit the invoices, which were again ...


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