reglab/statecodes huggingface dataset:
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9730 - Rights And Obligations Of The Contractor › Section 9730.3 - Prehearing responsibilities

Current through Register Vol. 46, No. 28, July 10, 2024
When the contractor is notified that a request for a fair
				  hearing has been received, it shall:
(a) send the appellant or his/her
				representative copies of all documents to be submitted into evidence at the
				hearing in support of the contractor's action;
(b) provide copies of any document or
				information in the file if requested by appellant or his/her representative,
				without charge;
(c) take such
				action as is necessary to assure that an appropriate representative will appear
				at the hearing with the case file and a brief written summary including:
(1) the names, addresses, relationships and
				ages of persons affected;
(2) the
				decision or action which prompted the request for the fair hearing;
(3) a brief description of the facts,
				evidence and reasons allegedly supporting such decision or action, including
				identification of the specific provisions of law or regulations which allegedly
				support the action;
(4) the income
				determination prepared for the appellant; and
(5) a copy of its determination upon
				reconsideration.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9730 - Rights And Obligations Of The Contractor › Section 9730.4 - Responsibilities and rights at the fair hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The contractor must provide complete
				copies of its documentary evidence to the hearing officer at the fair hearing
				and to the appellant or his/her representative, if such documents were not
				already provided. Such documents must be provided without a charge.
(b) The contractor must provide a
				representative at the hearing along with the file and a written summary of the
				case.
(c) Such representative must
				have the authority to make binding decisions at the hearing on behalf of the
				contractor, including the authority to withdraw the action.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9730 - Rights And Obligations Of The Contractor › Section 9730.5 - Compliance with fair hearing decision and mediation order

Current through Register Vol. 46, No. 28, July 10, 2024
The contractor must promptly comply with all fair hearing
				  decisions and initiate directives without delay, in accordance with this
				  Part.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.1 - Introduction

Current through Register Vol. 46, No. 28, July 10, 2024
The fair hearing process for persons applying for or
				  receiving coverage under the Program for Elderly Pharmaceutical Insurance
				  Coverage is governed by this Part.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.2 - Notice of hearing

Current through Register Vol. 46, No. 28, July 10, 2024
At least 10 calendar days prior to the date of the hearing,
				  written notice shall be sent to the parties and their representatives. The
				  notice shall inform them:
(a) of the
				date and place of the hearing and the appellant's right to a change in the date
				and place of the hearing where necessary;
(b) of the manner and means by which
				adjournments may be requested and granted;
(c) of the issues which are to be the subject
				of the hearing;
(d) of the manner
				in which the hearing will be conducted; and
(e) of the right of each party to be
				represented, to testify, to produce witnesses, to present documentary evidence
				and to examine opposing witnesses and evidence.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.3 - Scheduling and adjourning the hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The hearing shall be held at a time and
				place convenient to the appellant as far as practicable, taking into account
				circumstances such as the physical inability of the applicant to travel to the
				regular hearing location.
(b) Upon
				request, an appellant or the contractor may have the fair hearing rescheduled
				to another date upon a showing of good cause.
(c) The hearing officer may adjourn the
				hearing when he/she believes that due process rights of an appellant would best
				be served by adjourning the fair hearing or if there are special circumstances
				which make proceeding with the case fundamentally unfair.
(d) Requests to adjourn a fair hearing made
				prior to the date of the fair hearing must be made to the department in
				accordance with the instructions in the notice of fair hearing. Requests for
				adjournments made on the day of the fair hearing must be made on the record to
				the hearing officer.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.4 - Withdrawal or abandonment of a request for hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A request for a hearing is considered
				abandoned if neither the appellant nor his/her representative appears at the
				time and place agreed upon for the hearing or neither the appellant or his/her
				representative has contacted the department to reschedule the
				hearing.
(b) The department will
				consider a hearing request to be withdrawn only under the following
				circumstances:
(1) the department has
				received a written statement from the appellant or his/her representative
				stating that the request for a fair hearing is withdrawn; or
(2) the appellant or his/her representative
				has made a statement to the hearing officer withdrawing the request on the
				record at the hearing.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.5 - Hearing officer

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				hearing officer shall have all the powers conferred by law to require
				attendance of witnesses and the production of books and records, and to
				administer oaths and to take testimony.
(b) The hearing officer shall preside over
				the hearing.
(c) The contractor
				shall make an opening statement describing the nature of the proceeding, the
				issues and the manner in which the hearing shall be conducted.
(d) The hearing officer shall elicit
				testimony, review the evidence submitted by the parties, determine the
				credibility of the witnesses, examine the parties if necessary, and shall make
				findings of fact relevant to the issues of the hearing.
(e) The hearing officer shall also prepare an
				official report containing the substance of what transpired at the
				hearing.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.6 - Who may be present at hearing

Current through Register Vol. 46, No. 28, July 10, 2024
The appellant, his/her representative (who may be an attorney
				  or other persons representing him), counsel or other representative of the
				  contractor, the executive director, members of the panel or their agents,
				  witnesses of both parties or who may be called by the hearing officer, and such
				  other persons as the hearing officer in his/her discretion may admit, with the
				  consent of the appellant.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.7 - Fair hearing procedures

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Technical rules of evidence followed in a court of law shall not be followed,
				but evidence must be relevant and material.
(b) Irrelevant and unduly repetitious
				testimony and cross-examination may be excluded at the discretion of the
				hearing officer.
(c) The appellant
				shall have the burden of showing that its determination after reconsideration
				was incorrect.
(d) Records and
				documents in the possession of the contractor may be admitted as complete
				photocopies; however, the originals shall be available to the appellant or
				his/her representative for inspection at the direction of the hearing
				officer.
(e) The decision must be
				supported by and in accordance with substantial evidence.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.8 - Hearing record

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
				verbatim record of the hearing shall be made.
(b) The fair hearing testimony, the fair
				hearing exhibits, the written determination after reconsideration, the hearing
				officer's official report containing the substance of what happened at the fair
				hearing, all papers and requests filed in the proceeding prior to the close of
				the fair hearing, the findings of the hearing officer and the fair hearing
				decision constitute the complete and exclusive record of the fair
				hearing.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9740 - The Fair Hearing Process › Section 9740.9 - Examination of the record after hearing

Current through Register Vol. 46, No. 28, July 10, 2024
The record of the hearing shall be confidential, but it may
				  be examined by either party or their representatives, the executive director,
				  members of the panel or their agents at a place accessible to them and at a
				  reasonable time.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9750 - Decision And Compliance › Section 9750.2 - Decision after hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				hearing decision shall be made and issued in accordance with the agreement
				between the Department of Health and the panel, and shall be based exclusively
				on the record and testimony introduced at the hearing.
(b) The decision shall be issued as promptly
				as feasible and within 60 days from the date the request for a fair hearing is
				received by the department. The decision shall describe the issues, recite the
				relevant facts, the pertinent provisions of law, regulation and State-approved
				policy, make appropriate findings, determine the issues, state reasons for the
				determinations and, when appropriate, direct specific action.
(c) Where the issue at hearing involves the
				mere calculation of income or determination of the amount of any required fee,
				premium or deductible paid or to be paid, the hearing officer may issue a
				directive on the record, directing specific action by the contractor. Where
				such immediate directive is issued, a written memorandum decision shall be made
				setting forth the directive.
(d)
				The decision shall be binding on the parties.
(e) A copy of the decision or the memorandum
				of an immediate directive issued on the record, as appropriate, shall be sent
				to each of the parties and their representatives, if any.
(f) In the letter transmitting the decision,
				clear reference shall be made to availability of judicial review.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9750 - Decision And Compliance › Section 9750.3 - Decision without hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				The appellant shall have the option to request that his/her appeal from a
				contractor's determination after reconsideration be decided without a hearing.
				Such request will be granted when it is determined that no unresolved material
				issue of fact is involved in the case and that the only questions presented are
				questions of law. A request for a decision without a hearing must be
				accompanied by sufficient information to ascertain whether any unresolved
				material issue of fact exists, and should contain a full and clear statement of
				the issue and the appellant's position on the issue.
(b) Upon receipt of a request for a decision
				without a hearing which presents, on its face, no factual dispute, a copy of
				the request and any supporting documents will be sent to the contractor. Within
				10 working days of its receipt of the documents submitted by the appellant, the
				contractor shall forward, to the hearing officer, the appellant and the
				appellant's representative, its response containing sufficient information to
				ensure resolution of the dispute.
(c) The hearing officer shall make any
				further inquiries of the appellant, the appellant's representative and the
				contractor which are necessary to resolve the issues involved.
(d) If at any point after a request for a
				decision without a hearing is received, it appears that there is a material and
				unresolved issue of fact relating to the issue or issues upon which the hearing
				has been requested, the hearing officer shall inform the parties that a full
				hearing in accordance with the provisions of this Part must be scheduled to
				resolve the dispute, and the appellant shall then have the option of proceeding
				with such hearing or withdrawing the request for review.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9750 - Decision And Compliance › Section 9750.4 - Correction of error

Current through Register Vol. 46, No. 28, July 10, 2024
When a fair hearing decision has ordered the correction of a
				  discontinuance, the correction of a denial of an application for benefits or
				  the correction of the amount of cost-sharing responsibilities, a payment shall
				  be made to the appellant to cover the full amount to which he/she was entitled
				  in accordance with the decision for the entire period from the date the
				  incorrect action was taken.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9750 - Decision And Compliance › Section 9750.5 - Compliance with decision

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				When a decision directs the contractor to perform specific actions, the
				contractor shall comply within 10 calendar days with such direction.
(b) The appellant for whose benefit such
				direction was given shall address any inquiry concerning contractor compliance
				to the panel's executive director who shall ascertain compliance with such
				direction by such means as the executive director may deem necessary and
				appropriate under the circumstances of the case.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9800 - Enrollment Of Pharmacies › Section 9800.2 - Application for enrollment

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Information regarding application for enrollment may be obtained by writing to
				the provider enrollment unit of the contractor.
(b) Any person who furnishes covered drugs
				and who wishes to receive payments under the program must enroll as a provider
				of services prior to being eligible to receive such payments.
(c) A pharmacy-applicant must hold a proper
				and currently valid New York State pharmacy license and registration to be
				eligible to furnish the care, services or supplies under the program.
(d) To apply for enrollment as a provider of
				covered drugs, a pharmacy- applicant must submit a complete, original, signed
				and sworn application in the form and manner as may be required by the
				contractor. The ownership and disclosure form required by the contractor is
				part of the application.
(e) The
				contractor may require the provision of information relative to the
				pharmacy-applicant's ability to provide high-quality services and to be
				financially responsible.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9800 - Enrollment Of Pharmacies › Section 9800.3 - Duties of the provider

Current through Register Vol. 46, No. 28, July 10, 2024
By enrolling, the provider agrees:
(a) to prepare and to maintain
				contemporaneous records demonstrating its right to receive payment under the
				program and to keep, for a period of three years from the date care, services
				or supplies were furnished, all records necessary to disclose the nature and
				extent of services furnished and all information regarding claims for payment
				submitted by, or on behalf of, the provider, and to furnish such records and
				information, upon request, to the contractor, the panel, executive director, or
				agents and designees;
(b) to comply
				with the disclosure requirements with respect to ownership and control
				interests, significant business transactions and involvement with convicted
				persons;
(c) to accept payment from
				the program as payment in full for all covered drugs billed under the program,
				except where specifically provided in law to the contrary with respect to
				required copayments;
(d) not to
				illegally discriminate on the basis of handicap, race, color, religion,
				national origin, sex or age;
(e) to
				submit claims for payment only for covered drugs actually furnished and which
				were provided to eligible persons;
(f) to submit claims on officially authorized
				claim forms in the manner specified by the contractor in accordance with the
				standards and procedures for claims submission;
(g) to permit audits, by the persons and
				agencies denominated in subdivision (a) of this section, of all books and
				records or, in the discretion of the auditing agency, a sample thereof,
				relating to services furnished and payments received under the
				program;
(h) that the information
				provided in relation to any claim for payment shall be true, accurate and
				complete; and
(i) to comply with
				the rules, regulations of the program and official directives of the contractor
				and the executive director.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9800 - Enrollment Of Pharmacies › Section 9800.4 - Duties of the contractor

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Upon receipt of a complete, original and signed application, an appropriate
				review, at the direction of the executive director, shall be conducted to
				verify or supplement the information contained in the application. Incomplete
				applications shall be returned to the pharmacy-applicant within three working
				days with deficiencies noted.
(b)
				The contractor may request further information from a pharmacy-applicant. In
				such a case, it shall make a clear and precise request to the
				pharmacy-applicant for the information and inform the pharmacy-applicant
				whether or not action on the application will be postponed pending receipt of
				the requested information. Delay occasioned by the pharmacy-applicant's failure
				to timely reply shall not be counted in calculating the time within which the
				contractor shall make its determination on the application.
(c) The contractor shall complete its review
				and determine whether or not to enroll the pharmacy-applicant within 30
				calendar days after receipt of an application.
(d) If a pharmacy-applicant cannot be fully
				reviewed within the required time, the contractor may extend the time for
				acting on an application for up to one additional 30-day period from the date
				of receipt of the application. Written notice of this extension will be mailed
				to the pharmacy-applicant within 30 calendar days from the time the application
				was received.
(e) Upon completion
				of its consideration of an application, the contractor shall either:
(1) enroll the pharmacy-applicant as a
				provider; or
(2) deny the
				application, if it is in the best interests of the program to do so, specifying
				the reasons for denial.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9800 - Enrollment Of Pharmacies › Section 9800.6 - Acceptance of an application

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Upon acceptance of an application, the contractor shall issue to the provider a
				provider agreement, identification number and instructions on participation in
				the program and filing of claims for payment. Upon receipt of a complete,
				signed provider agreement, the contractor shall enroll the provider within 15
				working days.
(b) Enrollment,
				including the use of the identifying number, is not assignable or transferable
				but is strictly limited to the provider to which it was issued, unless
				authorized in writing by the contractor prior to the assignment or
				transfer.
(c) A provider's
				participation may begin only on or after the date specified in the notification
				of acceptance. A provider may participate in the program for the period
				specified in the notice of acceptance, unless participation has been otherwise
				terminated or suspended.
(d) A
				provider may submit claims only for services provided by the provider or
				another person under his supervision and in compliance with this
				Subtitle.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9800 - Enrollment Of Pharmacies › Section 9800.7 - Continued enrollment/termination

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A provider's participation in the program
				may be terminated by the provider upon 30 days' written notice to the
				contractor without cause.
(b) A
				provider's participation in the program may be terminated, suspended or
				restricted for a reasonable period of time if the provider has abused the
				program, and shall be terminated if the provider has engaged in
				fraud.
(c) A provider's
				participation shall be terminated or suspended as of the date of the provider's
				suspension or termination from Medicare or the medical assistance
				program.
(d) A provider's
				participation shall be terminated or suspended as of the date of any
				termination, revocation or suspension of its registration.
(e) A provider must maintain an up-to-date
				"Disclosure of Ownership and Control Interest Statement" on file with the
				contractor, amending it at least biennially or sooner when necessary to assure
				that the information contained in the statement is true, accurate and complete.
				Failure to maintain an up-to-date disclosure form on file, or to submit one
				within 35 days of a request by the contractor, will result in the termination
				of the provider's participation.
(f) A provider's participation may be
				terminated and a new application for enrollment required where the ownership or
				control of the provider has substantially changed since acceptance of its
				enrollment application, whether by the sale or exchange of the capital stock in
				a provider organized as a corporation, the addition or elimination of one or
				more partners in a provider organized as a partnership, or the sale of the
				business or assets of any provider entity.
(g) A provider's participation will be
				terminated where the provider furnished incorrect, inaccurate or incomplete
				information in connection with an application and where provision of correct,
				accurate and complete information would have resulted in the denial of the
				application based upon one or more of the factors set forth in section
				9800.5(a) 
				of this Part.
(h) Where a
				provider's participation is to be terminated, suspended or restricted, it is
				entitled to notice and an opportunity to be heard in accordance with the
				provisions of sections
				9850.7
				through
				9850.13  of
				this Title. The provider must be given written notice of the action at least 15
				days prior to its effective date, stating: the reasons for the action, the
				effective date, the effect of the action upon the provider's participation in
				the program, the earliest date on which participation may be reinstated, and
				the requirements for requesting a hearing.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9800 - Enrollment Of Pharmacies › Section 9800.8 - Audit and claim review

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Providers shall be subject to audit by the panel, the executive director, their
				agents or the contractor. With respect to such audits the provider may be
				required:
(1) to reimburse the contractor for
				overpayments discovered by audits; and
(2) to pay restitution for any direct or
				indirect monetary damage to the program resulting from their improperly or
				inappropriately furnishing covered drugs.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.1 - Scope

Current through Register Vol. 46, No. 28, July 10, 2024
(a) This Part
				establishes the procedures for the recovery of overpayments paid under the
				Program for Elderly Pharmaceutical Insurance Coverage, as determined by an
				audit of the provider's books, records, reports or other available
				documentation.
(b) Recovery of
				overpayments shall be made only upon a determination by the executive director
				that such overpayments have been made, and recovery shall be made of all money
				paid to the provider to which it has no lawful right or entitlement.
(c) Recovery of overpayments pursuant to this
				Part shall not preclude the executive director or any other authorized
				governmental body or agency from taking any other action with respect to the
				provider, including auditing or reviewing of other payments or claims for
				payment for the same or similar periods, imposing program sanctions, or taking
				any other action authorized by law.
(d) The existence of procedures for the
				recovery of overpayments pursuant to this Part shall not preclude the executive
				director from utilizing other lawful means to recover overpayments, including
				civil lawsuit, participation in a proceeding in bankruptcy, common law setoff,
				or such other actions or proceedings authorized or recognized by law.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The definitions employed in Part 9800 of this Title shall
				  apply equally in this Part, and as used in this Part the following terms shall
				  have the following meanings:
(a)
				Contractor shall mean the State fiscal intermediary making payments under the
				program, or any person or persons acting on behalf of the contractor.
(b) Executive director shall mean the
				executive director of the program.
(c) Office of Administrative Hearings shall
				mean that office within the Division of Legal Affairs of the State Department
				of Health which conducts hearings under contract with the panel.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.5 - Draft audit report

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If,
				after affording the provider the opportunity for a closing conference and after
				consideration of any additional documentation and information presented in
				connection therewith, the executive director or the contractor believes that
				overpayments have been made to the provider, a draft audit report shall be
				issued.
(b) The draft audit report
				shall contain a clear statement of the action to be taken. The items disallowed
				and the amount of the overpayments shall afford the provider the opportunity to
				object to the proposed action within 30 days and shall advise the provider that
				failure to object within the time provided may result in the adoption of the
				proposed action as the final action.
(c) The report shall be accompanied by a
				document identifying the person to whom objections to the report should be
				mailed. The provider's objections to the draft audit report must be mailed by
				the provider to that person within 30 days of the report. It shall include a
				statement detailing the specific items of the draft report to which the
				provider objects, and provide any additional material or documentation which
				the provider wishes to be considered in support of the objections.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.6 - Final audit report

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				After receipt of the provider's objections to the draft audit report, or at any
				time after the expiration of 40 days after mailing of the draft audit report
				without objections having been received, a final report shall be issued by the
				executive director. In preparing the final audit report for the executive
				director, the contractor shall consider the objections, any supporting
				documents and materials submitted therewith, the draft audit report, and any
				additional material which may become available.
(b) Upon receipt of a final report from the
				contractor, the executive director shall conduct a review of the report for
				conformance with program policy, law and regulations. The report may be
				modified by the executive director prior to issuance in light of his/her
				review.
(c) The final audit report
				and/or the cover letter accompanying it shall clearly advise the provider:
(1) of the nature and amount of the audit
				findings, the basis for the action and the statutory, regulatory or other legal
				basis therefor;
(2) of the action
				which will be taken;
(3) that the
				effective date of the intended action shall be not less than 15 days from the
				date of the final audit report;
(4)
				of the right to appeal the administrative action by requesting a hearing, and
				the name, title, address and telephone number of the appropriate official of
				the Office of Administrative Hearings the provider must contact to request a
				hearing;
(5) that a request for a
				hearing must be made in writing and postmarked or delivered within 60 days of
				receipt of the final audit report which shall be presumed to be five days from
				date of mailing; and
(6) that the
				request may not address issues regarding the methodology used to determine the
				rate of payment under the program or the dispensing fee, but shall be limited
				to those issues relating to determinations contained in the final audit
				report.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.7 - Request for hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
				provider has the right to an administrative hearing to challenge the final
				audit report and may request such a hearing within 60 days of receipt of the
				final audit report which shall be presumed to be five days from date of
				mailing.
(b) The request for
				hearing shall be in writing and shall be delivered or mailed to the appropriate
				official of the Office of Administrative Hearings. It shall specify by number
				and date the final audit report which is to be the subject of the hearing and
				shall include the following additional information:
(1) the specific item or items to which
				objections are made;
(2) the
				factual basis for the objections; and
(3) any legal authority for the
				objections.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.8 - The hearing officer

Current through Register Vol. 46, No. 28, July 10, 2024
The hearing shall be conducted by an impartial hearing
				  officer employed for that purpose. The hearing officer shall have all the
				  powers conferred by law and the regulations of the executive director to
				  administer oaths, issue subpoenas, require the attendance of witnesses and
				  production of records, rule upon requests for adjournment, rule upon
				  evidentiary matters, and to otherwise regulate the hearing, observe
				  requirements of due process and effectuate the purposes and provisions of
				  applicable law.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.9 - Who may be present at hearing; authorization of representative

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The hearing
				shall be open to the public. However, upon the hearing officer's motion, or
				upon the motion of either party, potential witnesses may be excluded from the
				hearing during the testimony of other witnesses.
(b) An individual, other than an attorney,
				representing the provider shall have written authorization signed by the
				provider if the operator thereof is a natural person, or by an officer, member
				or director of an operating entity which is not a natural person.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.10 - Conduct of hearings; rights of provider

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The hearing officer shall preside over
				the hearing, make all procedural rulings, and make a statement on the record
				describing the nature of the proceedings, the issues, and the manner in which
				the hearing will be conducted.
(b)
				The issues and documentation presented at the hearing shall be limited to
				issues relating to determinations made in the final audit report. A provider
				may not raise issues regarding the methodolgy used to determine the rate of
				payment or dispensing fee.
(c) The
				rules of evidence observed by a court of law need not apply.
(d) Computer-generated documents prepared by
				the contractor or its agent to show the nature and amount of payments made
				under the program shall be presumed, in the absence of evidence to the
				contrary, to constitute an accurate reflection of the contractor's records as
				to the amount and type of payment made to a provider as well as the basis for
				such payment.
(e) An extrapolation
				based upon a contractor audit utilizing a valid statistical sampling method
				shall be presumed, in the absence of evidence to the contrary, to be
				accurate.
(f) An audit report of
				the contractor shall be presumed to be correct and the burden of proof shall be
				on the provider to show by substantial evidence that any item of such report is
				incorrect.
(g) All testimony shall
				be given under oath or affirmation administered by the hearing
				officer.
(h) The provider shall be
				entitled to be represented, to have witnesses give testimony and to otherwise
				present relevant and material evidence on the provider's behalf, to
				cross-examine witnesses and to examine any document or other item offered into
				evidence.
(i) A verbatim record of
				the hearing will be maintained.
(j)
				In the discretion of the hearing officer, the hearing may be adjourned for good
				cause upon the request of either party or upon the hearing officer's own
				motion.
(k) The hearing shall be
				conducted in conformity with procedural requirements of section 12-a  of the Public Health Law and the State
				Administrative Procedure Act.
(l)
				At the conclusion of the hearing, the hearing officer may direct the provider
				and the contractor to submit memoranda on any legal issues relevant to the
				proceeding within time frames established by the hearing officer. The hearing
				officer may also direct the parties to submit proposed findings of
				fact.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.11 - The record

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				record shall include those matters required to be included by section 302 of
				the State Administrative Procedure Act, as amended from time to time, and the
				transcript of the proceedings.
(b)
				Findings of fact shall be based on the evidence at the hearing and on matters
				administratively noticed.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.12 - Examination of record after hearing

Current through Register Vol. 46, No. 28, July 10, 2024
The record and transcript of the hearing and the memoranda of
				  law or other post-hearing submissions of the parties may be examined by any
				  party to the hearing at the Office of Administrative Hearings during regular
				  business hours.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.13 - Decision after hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				hearing decision shall be made and issued in accordance with the agreement
				between the Department of Health and the panel and shall be based exclusively
				on the record and transcript of the hearing. In reaching a decision, memoranda
				of law of the parties, if any, may be reviewed and noted. The decision shall be
				in writing and shall describe the issues, recite the relevant facts, the
				pertinent provisions of law and regulations, make appropriate findings,
				determine the issues, state reasons for the determinations and, when
				appropriate, direct specific action.
(b) A copy of such decision shall be mailed
				to the provider and the provider's attorney or representative, if any, and to
				the contractor and executive director.
(c) In the event that a decision is adverse
				to the provider, in whole or in part, the provider shall be given notice of the
				right to judicial review in accordance with the provisions of article 78 of the
				Civil Practice Law and Rules.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.14 - Adjustments after audit

Current through Register Vol. 46, No. 28, July 10, 2024
Adjustments which result in revisions to the amount of
				  reimbursement made shall be satisfied pursuant to section
				  9850.15
				  or
				  9850.16 
				  of this Part.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.15 - Recoupment of overpayments

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Overpayments determined to have been made pursuant to this Part shall be
				recovered by withholding the provider's current or future payments on claims
				submitted or a percentage of payments otherwise payable on such claims, at the
				option of the contractor, unless the provider and contractor agree otherwise.
				Such withholding may be made at any time after the issuance of a decision after
				hearing or, if a hearing has not been requested in accordance with this Part,
				at any time after expiration of the time period allowed in section
				9850.7  of
				this Part for the making of such request.
(b) Any money due to the provider from the
				contractor shall be used as an offset against an overpayment determined to have
				been made by the audit made pursuant to this Part.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.16 - Recovery of overpayments pending hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Notwithstanding the provisions of
				subdivision (a) of section
				9850.15 
				of this Part, the executive director may request the contractor commence
				recoupment of overpayments by withholding all or part of payments otherwise due
				the provider, upon notice to the provider and not sooner than 15 days after
				issuance of the final audit report.
(b) If a request for hearing shall have been
				timely made and the Office of Administrative Hearings is unable to schedule the
				hearing so that it is commenced within 90 days of receipt of such request or if
				the contractor is unable to proceed within 90 days, any recovery begun under
				this section shall be stayed pending the commencement of the hearing. If a
				hearing shall have been scheduled to commence within 90 days of receipt of a
				hearing request, any delays or adjournments to the commencement of the hearing
				occasioned by or attributable to the contractor shall forestall the
				commencement of continuation of recoupment.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9850 - Audits And Recovery Of Overpayments › Section 9850.17 - Fraud and abuse

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				executive director shall maintain a statewide program for investigation and
				referral for prosecution of violations of State laws pertaining to fraud or
				abuse in the program.
(b) Whenever,
				in the conduct of an audit of the books and records of a provider or in the
				evaluation of utilization review reports or provider profiles, there is
				sufficient evidence of program fraud or abuse to warrant investigation of the
				provider, the contractor shall promptly refer the matter to the executive
				director for investigation.
(c)
				Where initial review of a contractor referral indicates substantial potential
				for criminal prosecution, the executive director shall refer the matter to the
				Attorney General or local prosecutive authority. Where initial review does not
				indicate substantial potential for criminal prosecution, the executive director
				shall conduct further investigation to determine whether or not the subject
				provider should be discontinued from participation in the program.
(d) Where investigation indicates substantial
				evidence of abusive practices on behalf of a provider or his affiliates, the
				provider may be terminated, suspended or restricted in accordance with the
				provisions of section
				9800.7(b) 
				of this Title.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9950 - Access To Records › Section 9950.1 - Statement of purpose

Current through Register Vol. 46, No. 28, July 10, 2024
The purpose of this Part is to set forth the methods and
				  procedures governing the availability, location and nature of those records of
				  the Elderly Pharmaceutical Insurance Coverage Panel subject to the provisions
				  of article 6 of the Public Officers Law, known as the Freedom of Information
				  Law, and the rules of the Committee on Open Government.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9950 - Access To Records › Section 9950.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Part, the following words and terms shall
				  have the indicated meanings:
(a)
				Statistical tabulation means a collection or orderly presentation of numerical
				data logically arranged in columns, rows or graphic representation. Opinions,
				policy options and recommendations do not constitute statistical
				tabulations.
(b) Factual tabulation
				means a collection of statements of objective information logically arranged
				and reflecting objective reality, actual existence or an actual occurrence.
				Opinions, policy options and recommendations do not constitute factual
				tabulations.
(c) Records access
				officer means the person designated as responsible for ensuring that the panel
				complies with provisions of the Freedom of Information Law and the regulations
				herein and coordinates the panel's response to requests for access to or copies
				of records.
(d) Records access
				appeals officer means the Executive Director, Elderly Pharmaceutical Insurance
				Coverage Panel, whose business address is: Empire State Plaza, Corning Tower,
				Albany, NY 12237.
(e) Record means
				any information kept, held, filed, produced or reproduced by, with or for the
				panel, in any physical form whatsoever, including but not limited to reports,
				statements, examinations, memoranda, opinions, folders, files, books, manuals,
				pamphlets, forms, papers, designs, drawings, maps, photos, letters, microfilms,
				computer tapes or discs, rules, regulations or codes.
(f) Trade secret means information which, if
				disclosed, would cause substantial injury to the competitive position of the
				subject enterprise.
(g) Panel means
				the Elderly Pharmaceutical Insurance Coverage Panel established by article 19-K
				of the Executive Law.
New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9950 - Access To Records › Section 9950.3 - Times and places for inspecting records

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Records shall be available for inspection
				and copying by members of the public and members of the news media on every day
				that the offices of the panel are open for the transaction of business between
				the hours of 8:30 a.m. and 4:45 p.m.
(b) Records may be inspected at locations
				designated by the records access officer, whose title and business address are
				as set forth in section
				9950.4 
				of this Part.