Appeal from the Order of the Department of Public Welfare, Office of Hearings and Appeals, in case of Appeal of: Allied Services for the Handicapped, Inc., Allied Services Long Term Care Facility, File Nos. 36-83-06; 36-83-07, and 23-83-105, dated August 15, 1985.
Mary Gardier Paterson, with her, Joseph A. O'Brien, Oliver, Price & Rhodes, for petitioner.
Diane J. Bartels, Assistant Counsel, for respondent.
Judges MacPhail and Palladino, and Senior Judge Blatt, sitting as a panel of three. Opinion by Judge Blatt. Judge Palladino dissents.
[ 107 Pa. Commw. Page 516]
Allied Services For The Handicapped, Inc. (Allied), has petitioned for review of an order of the Director of the Office of Hearings and Appeals (Director) of the Department of Public Welfare (Department). The Director's order had rejected the recommendation of the hearing examiner and denied Allied's appeal from the Department's refusal to pay certain medical assistance invoices pursuant to the General Provisions of the Medical Assistance Manual (Manual), 55 Pa. Code §§ 1101.11-1101.95.*fn1
Allied actually filed several appeals*fn2 from the Department's denial of provider reimbursement and the
[ 107 Pa. Commw. Page 517]
matter was scheduled for hearing by a Departmental hearing officer. A hearing was held and, thereafter, the hearing examiner issued his recommended decision which included the following material, comprehensive and specific findings of fact:
1. On January 1, 1981, DPW adopted the MAMIS SYSTEM for processing and payment of MA claims of long term care facilities, requiring that invoices must be submitted to DPW within 6 months of the date of service.
2. DPW did not enforce its 6 month limitation until March 1, 1982.
3. Many claims submitted by Allied Services (Allied), for services provided to qualified MA patients during the period January-November, 1981 (with most of those days of service occurring in February/March, 1981), in the amount of $41,214 [Ledger One], were not reflected as approved, rejected, or pended on the remittance advices (RA's); all claims were submitted within 180 days of date of service.
4. Allied was informed by Dottie Alexander, who was conducting provider training in the MAMIS system, at the training seminar held at the beginning of 1981, that when an RA came back and the claim was not approved, rejected or pended, that it was not to be resubmitted, but, ...