2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11 - Medical Assistance for Needy Persons › 365-G - Utilization Review for Certain Care, Services and Supplies.

§  365-g.  Utilization review for certain care, services and supplies.
1. The  department  may  implement  a  system  for  utilization  review,
pursuant  to  this section, for persons eligible for benefits under this
title,  to  evaluate  the  appropriateness  and   quality   of   medical
assistance,  and  safeguard  against unnecessary utilization of care and
services, which shall include a post-payment review process  to  develop
and  review beneficiary utilization profiles, provider service profiles,
and  exceptions  criteria  to  correct   misutilization   practices   of
beneficiaries  and providers; and for referral to the office of Medicaid
inspector general where suspected fraud, waste or abuse  are  identified
in  the  unnecessary  or inappropriate use of care, services or supplies
furnished under this title.
2. The department may review utilization  by  provider  service  type,
medical procedure and patient, in consultation with the state department
of   mental   hygiene,  other  appropriate  state  agencies,  and  other
stakeholders  including  provider  and  consumer   representatives.   In
reviewing   utilization,   the   department  shall  consider  historical
recipient utilization patterns, patient-specific diagnoses  and  burdens
of  illness,  and  the  anticipated recipient needs in order to maintain
good health. The system for utilization review  shall  not  be  used  to
determine  a  recipient's  medical care, services or supplies under this
section.
3. The utilization review established pursuant to this  section  shall
not  apply  to  developmental  disabilities services provided in clinics
certified under article  twenty-eight  of  the  public  health  law,  or
article twenty-two or article thirty-one of the mental hygiene law.
4.  Utilization  review established pursuant to this section shall not
apply to services, even though such services might otherwise be  subject
to utilization review, when provided as follows:
(a) through a managed care program;
(b) subject to prior approval or prior authorization;
(c) as family planning services;
(d) as methadone maintenance services;
(e) on  a  fee-for-services  basis to in-patients in general hospitals
certified under article twenty-eight of the public health law or article
thirty-one of  the  mental  hygiene  law  and  residential  health  care
facilities, with the exception of podiatrists' services;
(f) for hemodialysis; or
(g) through  or  by  referral  from  a preferred primary care provider
designated  pursuant  to  subdivision  twelve  of  section  twenty-eight
hundred seven of the public health law.
5.  The  department  shall  consult  with  representatives  of medical
assistance providers, social services districts, voluntary organizations
that represent or advocate on behalf of  recipients,  the  managed  care
advisory   council  and  other  state  agencies  regarding  the  ongoing
operation of a utilization review system.
6. On or before  February  first,  nineteen  hundred  ninety-two,  the
commissioner  shall  submit  to the governor, the temporary president of
the senate and the speaker  of  the  assembly  a  report  detailing  the
implementation  of  the utilization threshold program and evaluating the
results  of  establishing  utilization  thresholds.  Such  report  shall
include,  but  need  not  be limited to, a description of the program as
implemented; the number of requests for increases in service  above  the
threshold  amounts  by  provider  and  type  of  service;  the number of
extensions granted;  the  number  of  claims  that  were  submitted  for
emergency  care  or urgent care above the threshold level; the number of
recipients referred to managed care; an estimate of the  fiscal  savings
to   the  medical  assistance  program  as  a  result  of  the  program;

recommendations for medical condition that  may  be  more  appropriately
served  through managed care programs; and the costs of implementing the
program.