New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 5 - Procedures and Forms › Part 540 - Authorization Of Medical Care › Section 540.7 - Requirements for billing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) All
			 bills for medical care, services and supplies shall contain:
(1) patient name, case number and date of
			 service;
(2) itemization of the
			 volume and specific types of care, services and supplies provided (including
			 for a physician, his final diagnosis, and for drugs, the prescription
			 filled);
(3) the unit price and
			 total cost of the care, services and supplies provided;
(4) vendor name and address;
(5) the social security number or employer
			 identification number of the vendor in accordance with the following:
(i) When the provider of services is in solo
			 practice, or when the provider of supplies is in business by himself,
			 identification shall be by social security number.
(ii) When the provider of services is in
			 other than solo practice, identification shall depend upon the group's billing
			 practices; e.g., where the billing is by the individual, then identification
			 shall be by social security number.
(iii) Where billing is by a partnership or a
			 corporation, then identification shall be by employer identification
			 number.
(iv) Where billing is by a
			 medical facility (e.g., hospital, skilled nursing facility or health-related
			 facility) and such billing includes the cost of care provided by a physician,
			 the name and social security number of the physician shall be separately
			 stated;
(6) for the
			 initial billing only, the following documentation for persons admitted on or
			 after May 14, 1976 to skilled nursing facilities holding title XVIII provider
			 agreements shall be required. Claims for medical assistance payments shall not
			 be processed if any element of the required documentation as herein provided is
			 not submitted by the skilled nursing home operator:
(i) a copy of the New York State Health
			 Departments Long-Term Care Placement Form (DMS-1) or equivalent, properly and
			 legibly completed, which was submitted for skilled nursing coverage under title
			 XVIII;
(ii) additional forms and
			 documents necessary to assess the patient's medical condition or need for
			 skilled nursing home care and services and determined by the Commissioner of
			 Health or his designee;
(iii) a
			 written justification of the facility's decision not to submit to Medicare
			 because of the patient's apparent technical ineligibility for
			 coverage;
(iv) the official
			 Medicare denial notice received from the Bureau of Health Insurance or its
			 fiscal intermediary for this purpose; and
(v) a copy of the request for reconsideration
			 for skilled nursing facility coverage submitted to Medicare; or, in cases where
			 the skilled nursing facility agrees with the Medicare decision, a copy of the
			 skilled nursing facility's justification for agreeing with the Medicare
			 rejection;
(7) in the
			 case of hospital bills submitted to the local department of social services for
			 inpatient, general hospital care, services and supplies, the hospital shall
			 maintain on file the notification of coverability made by the Commissioner of
			 Health or his authorized representative attesting to the appropriateness and
			 necessity of such care, services and supplies in accordance with Part 505 of
			 this Subchapter. No billing for payment shall be made for care, services or
			 supplies for any period of time for which coverability has not been determined
			 by the Commissioner of Health or his designee;
(8) a dated certification by the provider
			 that the care, services and supplies itemized have in fact been furnished; that
			 the amounts listed are due and owing and that, except as noted, no part thereof
			 has been paid; that payment of fees and rates made in accordance with
			 established schedules is accepted as payment in full for the care, services and
			 supplies provided; that there has been compliance with title VI of the Federal
			 Civil Rights Act of 1964 in furnishing care, services and supplies without
			 discrimination on the basis of race, color or national origin; that such
			 records as are necessary to disclose fully the extent of care, services and
			 supplies provided to individuals under the New York State Medicaid program will
			 be kept for a period of not less than six years from the date of payment unless
			 otherwise required by regulation, and information will be furnished regarding
			 any payment claimed therefor as the local social services agency or the State
			 Department of Social Services may request; and that the provider understands
			 that payment and satisfaction of this claim will be from Federal, State and
			 local public funds and that he or she may be prosecuted under applicable
			 Federal and State laws for any false claims, statements or documents, or
			 concealment of a material fact provided, however, that each bill need not
			 contain the dated certification required by this paragraph in cases where the
			 care, services or supplies (other than the services of a clinical laboratory)
			 were furnished in a Canadian province or in a state other than the State of New
			 York by a provider with a principal place of business outside the State of New
			 York so long as the provider has previously filed with the department a
			 certification containing all of the provisions required by this paragraph which
			 will be applicable to all bills to be submitted by the provider during the
			 period of the provider's participation in the medical assistance
			 program.
(9)
(i) Prior to payment of a bill for a service
			 directly related to a sterilization or a hysterectomy, the State agency must be
			 in possession of the appropriate documentation.
(ii) For sterilization this is the DSS 3134,
			 "Sterilization Consent Form"; for hysterectomies, the DSS 3113, "Acknowledgment
			 of Receipt of Hysterectomy Information."
(10) In the case of bills for physician
			 services, physicians are required to maintain complete, legible records in
			 English for each patient treated. Medical records shall include at a minimum,
			 but not be limited to, the following:
(i) the
			 full name, address and medical assistance program identification of each
			 patient examined and/or treated in the office for which a bill is
			 presented;
(ii) the date of each
			 patient visit;
(iii) the patient's
			 chief complaint or reason for each visit;
(iv) the patient's pertinent medical history
			 as appropriate to each visit, and findings obtained from any physical
			 examination conducted that day;
(v)
			 any diagnostic impressions made for each visit;
(vi) a recording of any progress of a
			 patient, including patient response to treatment;
(vii) a notation of all medication dispensed,
			 administered or prescribed, with the precise dosage and drug regimen for each
			 medication dispensed or prescribed;
(viii) a description of any X-rays,
			 laboratory tests, electrocardiograms or other diagnostic tests ordered or
			 performed, and a notation of the results thereof;
(ix) a notation as to any referral for
			 consultation to another provider or practitioner, a statement as to the reason
			 for, and the results of such consultations;
(x) a statement as to whether or not the
			 patient is expected to return for further treatment, the treatment planned, and
			 the time frames for return appointments;
(xi) a chart entry giving the medical
			 necessity for any ancillary diagnostic procedure; and
(xii) all other books, records and other
			 documents as are necessary to fully disclose the extent of the care, services
			 and supplies provided.