1. Facility Name: ________________________________________________
2. Provider Number/Service Location: __________/_____________________________
3. Resident Name: ______________________________________________
4. Dates of Service: _____________________________________________
5. 180-Day exception is being requested due to:
[ ] A. Delay in processing the PA 162 by the CAO.
1. Date application was mailed to the CAO __________
2. Date of PA 162 __________
[ ] B. Delay in processing the third party payment/statement.
1. Date payment was requested from third party __________
2. Date payment/denial was processed by third party __________
NOTE: Please attach all documentation applicable to the dates indicated in item #5.
Completed by: ______________________ Date: __________________
Telephone No. ( ) - Ext:______
Before sending your exception request, did you remember to:
[ ] Enclose a correctly completed invoice (no file copies or photocopies)
[ ] Sign all invoices or attach a signed Signature Transmittal Form (MA 307)
[ ] Enclose all applicable documentation?
Mail to:
Office of Medical Assistance Programs
Division of Long Term Care Provider Services
ATTN: 180-Day Exception Unit
P.O. Box 8025
Harrisburg, PA 17105
Issued March 12, 2012