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MA Provider Obligations/Requirements Addressed in New OMAP Bulletins
August 1, 2001

The Office of Medical Assistance Programs (OMAP) has released two new “reminder” bulletins:

  1. #99-03-09 – Obligation of Medical Assistance (MA) Providers Participating in the Managed Care Delivery System to Comply with MA Regulations, and
  2. #99-03-10 – Requirement for Medical Assistance (MA) Providers to Submit Accurate and Complete Encounter Data to MA Managed Care Organizations.

Although neither of these bulletins imposes new requirements on providers, they indicate that the Department of Public Welfare is concerned about these issues and that providers are subject to periodic review by representatives of the Department, including the Bureau of Program Integrity, to ensure compliance with MA Program standards.

In Bulletin #99-03-09, OMAP notes:

While certain regulations governing billing and payment policies are exempted under the terms of the contract between the Department and MCOs, all providers are required to meet the fundamental regulatory requirements set forth in 55 Pa. Code §1101 (General Provisions). Examples of conduct prohibited by these requirements include the following:

  • Failure to maintain records or provide on-site access to state and federal reviewers;
  • Submission of false information to the Department or its contractors;
  • Submissions of claims for services that were not rendered;
  • Submissions of claims that misrepresent the description of service; and
  • Provision of services that are harmful to the recipient, of inferior quality, or medically unnecessary.

In Bulletin #99-03-10, the Department states:

This bulletin reminds providers that regulations governing their participation in the MA Program require that all encounter data be accurate, complete, and truthful. These regulatory requirements supplement existing contractual requirements relating to encounter data. The Department’s Bureau of Program Integrity will conduct periodic reviews of MA providers to ensure that providers comply with these regulatory requirements.

In discussion of OMAP Bulletin #99-03-10, the Department notes that despite existing requirements there are providers who continue to submit inaccurate or incomplete encounter data and, as a result, the data submitted to and used by the Department contains errors that jeopardize the Department’s ability to conduct utilization review and program management activities.

Both bulletins are available by accessing the OMAP web site at www.dpw.state.pa.us/omap/provinf/mabull/omapbullmain.asp and searching for the bulletins by number or by year of issue.

Questions can be directed to Kris Ericson, Rebecca May Cole, or Lynn Cooper at the Association.

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