An Act amending the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code, in fraud and abuse control, further providing for definitions and for restrictions on provider charges and payments and providing for claim submissions.

PRINTER'S NO. 1788
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No. 1373
Session of
2026
INTRODUCED BY BROOKS, LAUGHLIN, GEBHARD AND STEFANO,
JUNE 8, 2026
REFERRED TO HEALTH AND HUMAN SERVICES, JUNE 8, 2026
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 and for
restrictions on provider charges and payments and providing
for claim submissions.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The definition of "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
unique health identifier issued to a health care provider under
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45 CFR Pt. 162 Subpt. D (relating to standard unique health
identifier for health care providers).
"Person" means any individual, facility or entity.
* * *
"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 information in written, electronic or any other
format created, received or retained, or required to be created,
received or retained, by a person 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
to be retained by a provider under the medical assistance
program.
* * *
Section 2. Section 1406 of the act is amended by adding a
subsection to read:
Section 1406. Restrictions on Provider Charges and
Payments.--* * *
(c) (1) A provider shall submit information in a manner and
format as prescribed by the department in accordance with
Federal law, including the 21st Century Cures Act (Public Law
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114-255, 130 Stat. 1033).
(2) Electronic visit information reported shall include all
information under the definition of "electronic visit
verification system" under 42 U.S.C. § 1396b(l)(5)(A) (relating
to payment to states).
(3) The department or its contractors may deny a claim for
noncompliance with the reporting requirements of this
subsection.
Section 3. The act is amended by adding a section to read:
Section 1406.1. Claim Submissions.--(a) (1) The department
shall require every individual who delivers a health care
service in the home or the community which is not billed as a
per diem service under the medical assistance program to obtain
a National Provider Identifier.
(2) Clause (1) applies regardless of whether the individual
who delivers the health care service is the billing provider.
(b) All claims submitted for payment under the medical
assistance program for a health care service in the home or
community which is not billed as a per diem service, whether to
the department or any entity contracted with the department
under the medical assistance program, must include the
following:
(1) The NPI issued to the individual delivering the goods or
services to the recipient.
(2) The Medicaid provider number for the provider.
(3) Each date that goods or services were provided.
(4) The start and end time for each service provided.
(c) The department, in consultation with the Office of
Attorney General Medicaid Fraud Control Section, shall establish
a standardized medical assistance fraud recognition and training
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program for both individuals who deliver a health care service
in the home or community and entities that provide financial
management services.
(d) Notwithstanding any other provision in this section, the
department shall comply with Federal requirements regarding the
prompt payment of claims.
Section 4. The Department of Human Services 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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