reglab/statecodes huggingface dataset:
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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 521 - Fraud, Waste and Abuse Prevention › Subpart 521-3 - SELF-DISCLOSURE PROGRAM › Section 521-3.3 - Reporting and returning overpayments

Current through Register Vol. 46, No. 28, July 10, 2024
(a) General. Any person who has received an
			   overpayment under the MA program, directly or indirectly, shall report, return
			   and explain the overpayment by submission of a Self-Disclosure Statement to
			   OMIG's Self-Disclosure Program pursuant to section
			   521-3.4  of this SubPart.
(b) Deadline for reporting and returning
			   overpayments.
(1) If a person has received an
			   overpayment under the MA program, the person shall report and return the
			   overpayment and interest if applicable to the department, and explain the
			   reasons for the overpayment to OMIG by the later of:
(i) the date which is sixty (60) days after
			   the date on which the overpayment was identified; or
(ii) the date any corresponding cost report
			   is due, if applicable.
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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 521 - Fraud, Waste and Abuse Prevention › Subpart 521-3 - SELF-DISCLOSURE PROGRAM › Section 521-3.4 - Self-Disclosure Program

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			   General. Pursuant to subdivision 7 of section 363-d  of
			   the Social Services Law, the OMIG's SelfDisclosure Program is the process by
			   which persons who have identified an overpayment under the MA program report,
			   return and explain overpayments to the MA program. Persons required to report,
			   return and explain overpayments pursuant to section
			   521-3.3  of this SubPart shall
			   submit information regarding the overpayment to OMIG and make repayment in the
			   form and manner set forth in this section.
(b) Self-Disclosure Program - General
			   Provisions.
(1) Eligibility. A person is
			   eligible to participate in the Self-Disclosure Program if:
(i) the person is not currently under audit,
			   investigation, or review by OMIG. If the person is under audit, investigation,
			   or review, but the overpayment being disclosed does not relate to the existing
			   audit, investigation, or review the person shall be eligible to participate,
			   with respect to the overpayment being disclosed. For purposes of this
			   paragraph, an audit, investigation, or review includes, but is not limited to,
			   Parts 515, 516, 517, 518 and 521 of this Title;
(ii) the person is disclosing an overpayment
			   and related conduct that OMIG has not identified at the time of the
			   disclosure;
(iii) the overpayment
			   and related conduct are reported by the deadline specified in paragraph (1) of
			   subdivision (b) of section
			   521-3.3  of this SubPart;
			   and
(iv) the person is not
			   currently a party to or the subject of any criminal investigation, related to
			   their participation in the MA program, being conducted by the MFCU or an agency
			   of the United States Government or any political subdivision thereof.
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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 521 - Fraud, Waste and Abuse Prevention › Subpart 521-3 - SELF-DISCLOSURE PROGRAM › Section 521-3.5 - Returning the overpayment

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Once
			   OMIG has completed its review and verified the amount of the overpayment OMIG
			   shall notify the person of the amount of the overpayment and interest if
			   applicable, and such notification shall contain instructions for remitting
			   payment to the department. Interest may be waived in the sole discretion of
			   OMIG.
(1) The notification will be issued in
			   accordance with the provisions of subdivision (a) of section
			   521-3.6  of this SubPart.
(2) The person shall remit the full amount of
			   the overpayment and interest within fifteen (15) days of the date of OMIG's
			   notification of the determination of the amount of the overpayment, and
			   interest, unless the person has been approved by OMIG to repay the overpayment
			   through installments.
(3) Where a
			   person has been approved to repay the overpayment and interest through
			   installment payments, OMIG's notification of the amount of the overpayment
			   shall also include an SDCA which the person shall execute and return to OMIG
			   within the timeframe specified in paragraph (3) of subdivision (e) of section
			   521-3.4  of this SubPart.
(i) In order to remain eligible to
			   participate in OMIG's Self-Disclosure Program the person must comply with all
			   the terms of the SDCA, including the schedule of repayments.
(4) Notwithstanding any provision
			   tolling the deadline to report, return and explain, in no event shall the
			   person be required to repay the full amount of the overpayment and interest
			   prior to the expiration of the deadline to report, return and explain, as set
			   forth in paragraph (1) of subdivision (b) of section
			   521-3.3  of this SubPart.
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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 521 - Fraud, Waste and Abuse Prevention › Subpart 521-3 - SELF-DISCLOSURE PROGRAM › Section 521-3.6 - Notification

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Any
			   notification issued by OMIG to the person under this SubPart shall meet the
			   following requirements:
(1) Notification
			   shall be made by sending written notification to the person at:
(i) the person's designated payment address
			   or correspondence address or address provided on the Self-Disclosure Statement
			   submitted pursuant to subdivision (c) of section
			   521-3.4  of this SubPart;
			   or
(ii) an email address designated
			   on the Self-Disclosure Statement if the person so designates that email address
			   for receipt of electronic communication. It shall be the obligation of the
			   person electing to receive notification electronically to provide and maintain
			   a valid email address with OMIG. Proof of such email, containing a time and
			   date stamp, shall constitute sufficient notification that the electronic
			   communication was received by the person making such Self-Disclosure.
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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 521 - Fraud, Waste and Abuse Prevention › Subpart 521-3 - SELF-DISCLOSURE PROGRAM › Section 521-3.7 - Enforcement

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A person who
			   fails to report, return and explain an overpayment by the deadline specified in
			   subdivision (b) of section
			   521-3.3  of this SubPart may be
			   subject to monetary penalties pursuant to section 145-b (4)  of the Social
			   Services Law and Part 516 of this Title, and any other sanction or penalty
			   authorized by law.
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 4 - Fees and Reimbursement › Part 522 - Payment For Pre-school Children With Handicapping Conditions › Section 522.1 - Payment for medical care, service and supplies provided to pre-school children with handicapping conditions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Pursuant to section 368-e  of the Social Services Law, the
			 department shall review claims for expenditures made by counties and the City
			 of New York for medical care, services and supplies furnished to pre-school
			 children with handicapping conditions or pre-school children suspected of
			 having handicapping conditions, as defined in section 4401 (1)  of the Education
			 Law.
(b) Payment.
(1) Payment to counties and cities. Payment
			 for such medical care, services and supplies furnished to pre-school children
			 described in subdivision (a) of this section, which would otherwise qualify for
			 reimbursement under title 11 of article 5 of the Social Services Law and the
			 regulations of the department, shall be made in accordance with fees
			 established by the department and approved by the Director of the Budget, to
			 the county or city which furnished the care, services or supplies, either
			 directly or by contract.
(2)
			 Payment to clinics or diagnostic and treatment centers. Any clinic or
			 diagnostic and treatment center licensed under article 28 of the Public Health
			 Law, or article 16 or 31 of the Mental Hygiene Law, which submitted a claim for
			 such reimbursement payments on or before June 30, 1995, is authorized to
			 directly submit such claims for medical care, services or supplies furnished on
			 or before June 30, 1997.
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 4 - Fees and Reimbursement › Part 527 - State Reimbursement For Payment To Out-of-state Providers Of Medical Care And Services › Section 527.1 - Maximum reimbursable fee schedule

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Maximum reimbursable rates for payments
			 made to out-of-state providers of medical care and services shall be as
			 foliows:
(1) Effective January 1, 1984, for
			 inpatient hospital care, the lowest of the following charges:
(i) the title XIX payment established for the
			 hospital under the Medical Assistance Program in that state;
(ii) the title XVIII Medicare payment
			 established for the hospital;
(iii)
			 the hospital's customary charge for public beneficiaries; or
(iv) the maximum New York State title XIX
			 payment for similar inpatient care.
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 4 - Fees and Reimbursement › Part 530 - Hospital Rates › Section 530.1 - Basic policy

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For
			 admissions on or after January 1, 1988, payment for inpatient services will be
			 based on a prospective case payment reimbursement system in accordance with 10
			 NYCRR Part 86. Hospitals or hospital units that are exempt from the Medicare
			 prospective system are exempt from this case payment system and will continue
			 to be paid on a per diem basis. In addition, designated acquired immune
			 deficiency syndrome (AIDS) units and alcohol rehabilitation units are also
			 exempt, as described in 10 NYCRR 86-1.57, and will be paid on a per diem
			 basis.
(b) In addition to the case
			 payment rate, a hospital may receive a long length of stay outlier payment
			 calculated pursuant to 10 NYCRR 86-1.55(b), a high cost outlier payment
			 calculated pursuant to 10 NYCRR 86-1.55(c), or an alternative level of care
			 payment calculated pursuant to 10 NYCRR 86-1.56, if the conditions for such
			 payments, as set forth in 10 NYCRR Part 86, are satisfied. Further, in lieu of
			 case-based rates of payments, a hospital may receive a short length of stay
			 outlier payment calculated pursuant to 10 NYCRR 86-1.55(a) or a transfer
			 payment calculated pursuant to 10 NYCRR 86- 1.54(l) if the conditions for such
			 payments, as set forth in 10 NYCRR Part 86, are satisfied.
(c) The date of admission or the date of
			 discharge may be counted as a day of care but in no instance will both the day
			 of admission and the day of discharge be reimbursable.
(d) A hospital may be reimbursed for an
			 interim billing on the basis of an inpatient admission, reconciled to final
			 payment on the basis of discharge date, with such reconciliations established
			 at time periods specified by the department. Under such a system, variances
			 between amounts paid on an admission basis and actual amounts due and to be
			 paid on a discharge basis may be reflected in the amounts to be paid on an
			 admission basis. The failure by a hospital to submit a discharge bill within
			 the time period specified by the department will result in the recovery of the
			 amount paid on an admission basis.
(e) If welfare districts plan to pay
			 hospitals for X-ray, laboratory, electrocardiogram, metabolism and related
			 services for outpatients on a fee-for-service basis, the costs of operating
			 these services for outpatients must be excluded from the statement of operating
			 costs upon which the per diem rate for inpatient care is based.
(f) Hospital care is reimbursable for State
			 charges for the entire approved period of hospital care when such care is
			 rendered pursuant to section
			 505.4  of this
			 Title.
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 4 - Fees and Reimbursement › Part 531 - Reimbursement For Ma Provided To Presumptively Eligible Applicants › Section 531.1 - Basic policy

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Medical
			 assistance payments for care and services provided during a period of
			 presumptive eligibility, as described in section 360.24(d) of this Title, will
			 be made from State funds. Payment for services provided by a certified home
			 health agency or a long-term home health care program during the period of
			 presumptive eligibility will not exceed 65 percent of the established medical
			 assistance rate for such services. After the applicant is determined to be
			 eligible for medical assistance, payment will be made for the remaining 35
			 percent of the cost of such services, and a retroactive adjustment will be made
			 to reflect Federal financial participation and the local share of costs for all
			 medical assistance provided during the period of presumptive
			 eligibility.
(b) Except as provided
			 in subdivision (c) of this section, if an applicant presumed eligible for
			 medical assistance is subsequently determined to be ineligible, the cost for
			 services provided during the period of presumptive eligibility will be
			 reimbursed in accordance with the provisions of section 368-a (1)(g)  of the Social
			 Services Law.
(c) If, after an
			 audit, the department determines that subsequent determinations of
			 ineligibility have occurred in at least 15 percent of the cases in which
			 presumptive eligibility has been granted by a particular social services
			 district, payments for care and services provided to all persons presumed
			 eligible pursuant to section 360.24(d) of this Title, and subsequently
			 determined ineligible, will be divided equally between the State and the
			 district.
(d) The payment policy
			 described in this Part applies to care and services provided on or after May 1,
			 1988.
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 4 - Fees and Reimbursement › Part 531 - Reimbursement For Ma Provided To Presumptively Eligible Applicants › Section 531.2

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 531 - Reimbursement For Ma Provided To Presumptively Eligible Applicants › Section 531.3

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 532 - Payment To Physicians › Section 532.1 - Fees

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Payment for
			 scheduled services. Social services districts shall establish fees for the
			 services and procedures listed in Part 533. The schedule of such fees shall be
			 classified as "Medicine", "Anesthesia", "Surgery" and "Radiology" and shall be
			 included in the local medical plan.
(b) Payment for nonscheduled services. If a
			 service or procedure not included in the fee schedule established pursuant to
			 subdivision (a) of this section has been or is required to be rendered, the
			 value therefor shall be established by the social services district, utilizing
			 the most closely related procedures listed in the fee schedule as a base. The
			 fee so established shall be reported promptly to the department and to the
			 Division of Health Economics of the State Department of Health.
(c) State reimbursement for payments to
			 physicians under the Medical Assistance for Needy Persons program shall be
			 available only for services rendered by a physician meeting the qualifications
			 for general practitioners and specialists as set forth in Part 505 of the
			 regulations of the department, or by a registered physician's associate or a
			 registered specialist's assistant employed by such physician.
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.1 - Payment for physician's services to hospitalized patients

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Expenditures by social services districts
			 for their payments to a physician for services rendered to a hospitalized
			 patient shall be subject to State reimbursement as follows:
(1) when the physician has the responsibility
			 for the care of the patient; or
(2)
			 when the physician's services were rendered as a consultant, surgical
			 assistant, or for a special service at the request of the physician responsible
			 for the care of the patient.
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
When used in this Part, unless otherwise expressly stated
			   or unless the context or subject matter requires a different interpretation,
			   the terms hereinafter set forth shall be interpreted in accordance with the
			   definitions herein provided.
(a)
			 Reimbursement shall mean State reimbursement.
(b) Maximum reimbursable allowance shall mean
			 that portion of the expenditures for any service or procedure which is subject
			 to reimbursement.
(c) By report
			 shall mean the maximum reimbursable allowance determined on an individual
			 basis, in consideration of the nature, extent, and need for the procedure or
			 service, the time, skill and equipment necessary therefor, and such other
			 factors as may be pertinent.
(d)
			 Clinic fees shall mean fees for services provided in organized clinics of
			 hospitals possessing valid operating certificates issued by the New York State
			 Department of Health and for services of physicians in providing prior arranged
			 group care, outside a hospital clinic setting in the physically handicapped
			 children's program and in the New York State vocational rehabilitation
			 program.
(e) Consultation shall
			 mean the advice and counsel, from an accredited specialist called in by the
			 responsible physician, necessary to further treatment of the case by the
			 responsible physician.
(f)
			 Conversion factor shall mean the dollar amount by which the value of a
			 procedure or service is multiplied to determine the maximum reimbursable
			 allowance.
(g) Value shall mean the
			 relative factor assigned to a procedure or service by which the conversion
			 factor is multiplied to determine the maximum reimbursable allowance.
(h) Home call shall mean services rendered to
			 a patient in a private household or in a boarding home, nursing home,
			 convalescent home, proprietary home for adults, private home for the aged,
			 institution for the blind, or child caring institution.
(i) New illness shall mean an illness or
			 condition for which the patient has not received continuous or intermittent
			 care from the physician providing the service.
(j) Referral shall mean the transfer of a
			 patient from one physician to another for definitive treatment.
(k) The notation T shall mean one time unit
			 for each 15 minutes of anesthesia time.
(l) Services or procedures shall mean the
			 services or procedures provided by a physician or an osteopathic
			 physician.
(m) Intensive care shall
			 mean extraordinary care by the responsible physician in personal attendance in
			 the care of a medical emergency, both directing and personally administering
			 specific corrective measures after initial examination has determined the
			 nature of the ailment.
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.3 - State reimbursement

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Basis for reimbursement. Reimbursement for physicians' services for which a
			 maximum reimbursable allowance has been established in this Part shall be based
			 upon payments actually made. However, reimbursement shall not be available for
			 amounts paid in excess of the maximum reimbursable allowance prescribed nor for
			 services not included in Part 505 of this Subchapter.
(1) If a physicians' service or procedure for
			 which no maximum reimbursable allowance has been established in this Part is
			 necessarily rendered, reimbursement shall be based upon the expenditures
			 actually made therefor, in accordance with applicable regulations of the
			 department.
(2) If, in accordance
			 with the accepted practice, a physician's service or a procedure hereinafter
			 listed in this Part is commonly carried out as an integral part of the total
			 service, only the value of the principal service or procedure shall be the
			 basis for reimbursement. When such a procedure is carried out as a separate
			 entity not immediately related to other services, reimbursement shall be based
			 upon the fee for the particular service or procedure.
(i) When a special procedure is performed
			 during a medical emergency when the physician is rendering intensive care,
			 items 9072 and 9073, for which there would be a separate allowance,
			 reimbursement shall be available for the higher of the two allowances, i.e.,
			 the allowance for service or allowance for time.
(3) If immunization is administered at the
			 time of an office visit, reimbursement will be based upon the immunization fee
			 in addition to the fee appropriate for the level of services provided during an
			 office visit.
(4) Charges for
			 special diagnostic procedures which are not considered to be a routine part of
			 a physician's or consultant's examination ( e.g., complete blood count,
			 diagnostic X-ray, lumbar puncture) are reimbursable in addition to the
			 physician's usual office or home visit fee.
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.4 - Medicine

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Conversion factor.
The conversion factor for the services and procedures
			   listed in subdivision (g) of this section shall be $5.
(b)
Services and values.
For the numbered and described items of services or
			   procedures set forth in subdivision (g) of this section, the maximum
			   reimbursable fee shall be computed on the basis of the respective assigned
			   value multiplied by the conversion factor of $5.
(c)
Clinic services.
(1) Maximum reimbursable allowances
			 established for payment to a physician for clinic services (items 9023, 9024,
			 9032, 9033, 9026, 9027, 9030, 9031) shall not apply when the physician receives
			 any form of compensation from the facility for providing such
			 services.
(2) Clinic fees (items
			 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall be prorated according to
			 the number of medical assistance patients treated as a percentage of the total
			 number of patients seen during a clinic session.
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.5 - Anesthesia and surgery

Current through Register Vol. 46, No. 28, July 10, 2024
All fees billed must be in accordance with the provisions
			   of Part 505 of this Subchapter.
(a)
Anesthesia.
(1) The conversion
			 factor for the anesthesia services and procedures listed in this section shall
			 be $5.
(2) Anesthesia values.
(i) The total values for anesthesia services
			 include pre- and post-operative visits, the administration of the anesthesia
			 and the administration of fluids and/or blood incident to the anesthesia or
			 surgery.
(ii) Calculated values for
			 anesthesia services shall be used only when the anesthesia is personally
			 administered by a licensed physician who remains in constant attendance during
			 the procedure for the sole purpose of rendering such anesthesia
			 services.
(iii) For anesthesia
			 procedures, the same item number as the related surgical procedure shall be
			 used with the suffix "a" added.
(iv) When hypothermia and/or pump oxygenator
			 are employed in conjunction with an anesthesia, the anesthesia "basic" value
			 shall be 20 units instead of the "basic" value presently listed and the suffix
			 "y" shall be substituted for "a".
(v) If the general or regional anesthetic is
			 administered by the attending surgeon, the value shall be 50 percent of the
			 calculated value and the suffix "p" shall be substituted for "a".
(vi) In procedures where no value is listed,
			 the basic portion of the calculated value shall be the same as listed for a
			 comparable procedure.
(vii)
			 Necessary drugs and materials provided by the physician anesthetist may be
			 charged for separately.
(viii)
			 Where unusual detention with the patient is essential for the safety and
			 welfare of such patient, the necessary time shall be valued on the same basis
			 as indicated below for anesthesia time.
(ix) No fee shall be allowed for local
			 infiltration or digital block anesthesia administered by the operating
			 surgeon.
(3) Calculation
			 of total anesthesia values.
Calculation of total anesthesia value shall be determined
			   by adding the listed basic value and time units. The time units shall be
			   computed by allowing one unit for each 15 minutes of anesthesia time.
			   Anesthesia time shall start with the beginning of the administration of the
			   anesthetic agents and shall end when the physician anesthetist is no longer in
			   personal attendance.
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.6 - Radiology

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Maximum payment
			 for radiology services. The department will reimburse providers of radiology
			 services according to the radiology fees listed in the relevant Radiology Fee
			 Schedule at
https://www.emedny.org/ProviderManuals/Radiology/index.aspx
or
https://www.emedny.org/ProviderManuals/OrderedAmbulatory/index.aspx
.
			 Unless otherwise indicated, these fees are full payment for the radiology
			 service provided.
(b) Radiology fee
			 components. The fees listed in each Radiology Fee Schedule set forth in
			 subdivision (a) of this section include payment for the professional component
			 and/or the technical and administrative component of radiology services.
(1) Professional component. The professional
			 component of radiology services refers to the various professional services
			 performed by physicians, including:
(i)
(a) for interventional radiology services,
			 determining the patient's problem, including interviewing the patient,
			 obtaining the patient's medical history, and examining the patient to decide
			 how to perform radiology procedures;
(b) for diagnostic radiology services,
			 reviewing relevant clinical information as presented by the ordering or
			 referring physician, including the basis for performing the radiology
			 study;
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.7 - Preferred Physicians and Children Program

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Scope. The Preferred Physicians and
			 Children Program (PPAC) is a program under which a written agreement is entered
			 into by a provider and the department pursuant to which the department pays
			 enhanced fees for certain medical services provided to children under the age
			 of 21 who are eligible for Medical Assistance (MA). Only qualified primary care
			 and specialist physicians meeting the requirements of this section are eligible
			 to participate in PPAC. Physicians who wish to participate in PPAC must apply
			 in writing on forms provided by the department. Applications for participation
			 will be reviewed by and must receive approval of the department and the
			 Department of Health. Participating physicians may obtain payment at the
			 enhanced fees for medical services by using special PPAC procedure codes on
			 their MA claims.
(b) Purpose. The
			 purpose of PPAC is to improve access to quality medical care for MA-eligible
			 children by paying enhanced MA fees to physicians meeting the minimum criteria
			 for program participation.
(c)
			 Definitions.
(1) Medical care coordination,
			 for purposes of this section, means providing or arranging for the provision
			 of:
(i) scheduling of elective hospital
			 admissions;
(ii) assistance with
			 emergency admissions;
(iii)
			 management of and/or participation in hospital care and discharge
			 planning;
(iv) scheduling of
			 referral appointments with written referrals as necessary and with requests for
			 follow-up reports;
(v) scheduling
			 of necessary ancillary services;
(vi) telephone notification to the social
			 services district responsible for furnishing MA to the recipient when
			 transportation services are essential to ensure the MA recipient's access to
			 medically necessary care and services provided under the MA program;
			 and
(vii) maintenance of complete
			 medical records in compliance with the requirements of section
			 540.7  of
			 this Title, including notation of referrals and hospitalizations, and copies of
			 test results and reports.
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.8 - Human Immunodeficiency Virus Enhanced Fees for Physicians Program (HIV-EFP)

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Scope.
			 The HIV-EFP is a program under which a written agreement is entered into by a
			 provider and the department pursuant to which the department agrees to pay
			 enhanced fees for certain medical services provided to HIV-infected Medical
			 Assistance (MA) recipients. Only qualified primary care and specialist
			 physicians meeting the requirements of this section are eligible to participate
			 in the HIV-EFP. Physicians who wish to participate in the HIV-EFP must apply in
			 writing on forms provided by the department. Applications will be reviewed by
			 and must receive approval of the department and the Department of Health.
			 Participating physicians may obtain payment at the enhanced fees for medical
			 services provided to HIV-infected MA recipients by using special HIV-EFP
			 procedure codes on their MA claims.
(b) Purpose. The purpose of the HIV-EFP is to
			 improve access to quality medical care for HIV-infected MA recipients by paying
			 enhanced fees to physicians meeting the minimum criteria for program
			 participation.
(c) Definitions.
(1) Medical care coordination, for purposes
			 of this section, means providing or arranging for the provision of:
(i) scheduling of elective hospital
			 admissions;
(ii) assistance with
			 emergency admissions;
(iii)
			 management of and/or participation in hospital care and discharge
			 planning;
(iv) scheduling of
			 referral appointments with written referrals as necessary and with requests for
			 follow-up reports;
(v) scheduling
			 of necessary ancillary services such as laboratory, radiology, aerosolized
			 pentamidine, physical therapy and infusion therapy;
(vi) telephone notification to the social
			 services district responsible for furnishing MA to the recipient when
			 transportation services are essential to ensure the MA recipient's access to
			 medically necessary care and services provided under the MA program;
			 and
(vii) maintenance of complete
			 medical records in compliance with the requirements of section
			 540.7  of
			 this Title including, but not limited to, notation of referrals and
			 hospitalizations, and copies of test results and reports.
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.9

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.10

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.11

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.12

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.13

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.14

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.15 to 533.17

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 533 - State Reimbursement For Payment To Physicians › Section 533.18 to 533.22

Current through Register Vol. 46, No. 28, July 10, 2024
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 4 - Fees and Reimbursement › Part 535 - State Reimbursement For Payment To Dentists › Section 535.1 - Payment for dentists' services to hospitalized patients

Current through Register Vol. 46, No. 28, July 10, 2024
[Additional statutory authority: Social Services Law,
			   §368-a ]
(a) Expenditures by
			 social services districts for their payments to dentists for services rendered
			 to a hospitalized patient shall be subject to State reimbursement as follows:
(1) only if such services are determined to
			 be coverable benefits under the provisions of Part 505 of this Subchapter, by
			 the State Commissioner of Health or his designee; or
(2) when the dentist has the responsibility
			 for the care of the patient; or
(3)
			 when the dentist's services are rendered as a consultant, surgical assistant,
			 or for a special service, at the request of the attending dentist or physician
			 responsible for the care of the patient.
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 4 - Fees and Reimbursement › Part 535 - State Reimbursement For Payment To Dentists › Section 535.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
[Additional statutory authority: Social Welfare Law,
			   § 368-a] When used in this Part, unless otherwise expressly stated or
			   unless the context or subject matter requires a different interpretation, the
			   terms hereinafter set forth shall be interpreted in accordance with the
			   definitions herein provided.
(a)
			 Reimbursement means State reimbursement.
(b) Maximum reimbursable allowance means that
			 portion of the expenditures for any dental service or procedure which shall be
			 subject to reimbursement.
(c)
			 Dentist includes periodontist, endodontist and oral surgeon.
(d) Attending dentist means that dentist who
			 is primarily and continuously responsible for the service or procedures
			 rendered to a patient.
(e)
			 Consultation means advice and counsel from an accredited specialist called in
			 by the attending dentist in regard to the further handling of the case by the
			 attending dentist.
(f) Referral
			 shall mean the transfer of a patient from one dentist to another for definitive
			 treatment.
(g) Anesthesia time
			 means that time elapsing from the beginning of the administration of the
			 anesthetic agent until the anesthetist is no longer in personal
			 attendance.
(h) the notation T
			 means one time unit for each 15 minutes of anesthesia time during in-hospital
			 oral surgery.
(i) By report means
			 that the maximum reimbursable allowance is determined on an individual basis in
			 consideration of the nature, extent and need for the procedure or service, the
			 time, skill and equipment necessary therefor, and such other factors as may be
			 pertinent.
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 4 - Fees and Reimbursement › Part 535 - State Reimbursement For Payment To Dentists › Section 535.3 - State reimbursement

Current through Register Vol. 46, No. 28, July 10, 2024
[Additional statutory authority: Social Welfare Law,
			   §§ 365-b, 368-a]
(a) State
			 and local charges.
(1) State reimbursement
			 for local charges shall be based on payments actually made, except that in no
			 case shall reimbursement be available for amounts paid in excess of the maximum
			 reimbursable allowance hereinafter prescribed.
(i) If a service or procedure, which is not
			 listed in section
			 535.5 
			 of this Part, is necessarily performed, reimbursement shall be based on the
			 expenditures actually made therefor, in accordance with applicable rules of the
			 board and regulations of the department.
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 4 - Fees and Reimbursement › Part 535 - State Reimbursement For Payment To Dentists › Section 535.4 - Anesthesia

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Anesthesia
			 services for in-hospital oral surgery.
(1)
			 Expenditures by social services districts for anesthesia services for
			 in-hospital oral surgery shall be reimbursable:
(i) if the anesthetic is administered
			 personally by a qualified dentist or physician who remains in constant
			 attendance during the procedure for the sole purpose of rendering such
			 anesthesia service; and
(ii) if the
			 Commissioner of Health or his designee determine such care, services and
			 supplies are coverable benefits under the provisions of Part 505 of this
			 Subchapter.
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 4 - Fees and Reimbursement › Part 537 - State Reimbursement For Optometric Services › Section 537.1 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
Social Services Law, §§ 364, 365-a
When used in this Part, unless otherwise expressly stated
			   or unless the context or subject matter requires a different interpretation,
			   the terms hereinafter set forth shall be interpreted in accordance with the
			   definitions herein provided.
(a)
Reimbursement
shall mean State reimbursement.
(b)
Maximum reimbursable
			 allowance
shall mean that portion of the expenditure for any
			 optometric service which shall be subject to reimbursement.
(c)
Optometric examination
shall include diagnosis for optical deficiency or deformity and the visual or
			 muscular anomaly of the human eye, by an optometrist.
(d)
By report
shall mean the
			 maximum reimbursable allowance determined on an individual basis, in
			 consideration of the nature, extent and need for the service, the time, skill
			 and equipment necessary therefor, and such other factor as may be
			 pertinent.
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 4 - Fees and Reimbursement › Part 537 - State Reimbursement For Optometric Services › Section 537.2 - Reimbursement

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Local charges.
			 Reimbursement for local charges shall be based on payments actually made,
			 except that in no case shall reimbursement be available for amounts paid in
			 excess of the maximum reimbursable allowance hereinafter prescribed.
(b) State charges. The full amount paid for
			 optometric services State charges shall be eligible for reimbursement, provided
			 that such payment is the same as that which would be made for local charges in
			 similar circumstances.
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 4 - Fees and Reimbursement › Part 537 - State Reimbursement For Optometric Services › Section 537.3 - Reimbursement for payment to self-employed and salaried optometrists, dispensing opticians and retail optical establishments

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
General information and
			 instructions.
(1) " ____" Underlined
			 code numbers indicate that prior approval is required.
(2) The fees listed in the following schedule
			 apply to self-employed and salaried optometrists, dispensing opticians and
			 retail optical establishments. Ophthalmologists cannot bill under these fee
			 codes.
(3) Code number "60020
			 Disposition fee for undelivered eyeglasses", shall be used only when the
			 recipient fails to pick up his eyeglasses within 60 days following notification
			 that they were ready. Refer to the fee schedule for the appropriate
			 fee.
(4) When billing "by report"
			 the provider must submit with his/her claim form, a statement which indicates
			 the nature, extent, and need for the service; the time, skill and equipment
			 required, including appropriate documentation (
e.g.,
itemized
			 invoice) indicating the total cost of any items or materials, and any other
			 factors which may be pertinent.
(5)
			 Code number "60009" shall be used for home visit services provided to persons
			 in places of residence used as individual's home (including boarding homes,
			 nursing homes, convalescent homes, proprietary homes for adults or for the
			 aged, institutions for the blind, etc.).
(6) "Clinic sessions" (codes 60048, 60049,
			 60050, 60051), divide the appropriate procedure code fee by the total number of
			 patients (Medicaid and non-Medicaid) in the session. The resulting amount
			 should be claimed from Medicaid for each Medicaid recipient in the
			 session.
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 4 - Fees and Reimbursement › Part 537 - State Reimbursement For Optometric Services › Section 537.5

Current through Register Vol. 46, No. 28, July 10, 2024