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 510 - Chiropractic Services › Section 510.1 - Qualifications of chiropractors

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 General qualifications. Qualified chiropractors under the medical assistance
			 program shall be:
(1) those who have been
			 granted and issued a license to practice chiropractic by the State Education
			 Department pursuant to article 132 of the State Education Law and who are the
			 holders of a current valid registration certificate issued by the State
			 Education Department pursuant to article 132 of the State Education Law,
			 rendering them legal practitioners of chiropractic; or
(2) those who are certified on lists or
			 otherwise in writing by the State Education Department as being applicants
			 accepted as present practitioners for qualifying examinations for chiropractic
			 licensure; or
(3) those who
			 practice outside the State of New York and are duly licensed or recognized as
			 entitled to engage in the practice of chiropractic in that state.
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 510 - Chiropractic Services › Section 510.2 - State reimbursement

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 State reimbursement shall be available for payments to chiropractors meeting
			 the requirements provided in section
			 509.1 
			 of this Part, for chiropractic services as defined in article 132 of the State
			 Education Law, made in accordance with fee schedules established by the social
			 services district, but reimbursement shall not be available for payments made
			 in excess of the maximum reimbursable fees promulgated by the Director of the
			 Budget.
(b) State reimbursement
			 shall not be available for expenditures made for the following:
(1) chiropractic services beyond the third
			 visit, when a satisfactory treatment plan has not been received within 10 days
			 of that visit;
(2) chiropractic
			 services rendered after the 10th day of a subsequent month when a progress
			 report or amendment of the treatment plan has not been received for the
			 preceding month;
(3) chiropractic
			 services rendered to a patient not referred to a physician after such time as
			 the chiropractor identifies or suspects presence of a disease, disorder or
			 disability not treatable by the practice of chiropractic, or after conference
			 with the local medical director or his designee indicates need for referral to
			 a physician, except in the instances where the patient refuses to accept the
			 services of a 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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 510 - Chiropractic Services › Section 510.3 - Authorization

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Prior
			 authorization is not required for chiropractic services.
(b) Patients shall have free choice of
			 chiropractors qualified in accord with section
			 510.1 
			 of this Part.
(c) The chiropractor
			 shall submit to the social services district a treatment plan, as outlined
			 under subdivision (d) of this section, in all instances of more than three
			 visits by or to a patient for a given illness. Such treatment plan shall be
			 submitted prior to the fourth visit but further treatment may be continued as
			 necessary unless consultation between chiropractor and medical director
			 indicates other course.
(d) The
			 treatment plan shall follow a form prescribed by the State Department of Health
			 and shall indicate the following:
(1)
			 Patient's subjective complaints:
(i) present
			 complaint and nature of symptoms;
(ii) other symptoms observed which may
			 indicate therapeutic requirements beyond statutory scope of
			 chiropractic.
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 510 - Chiropractic Services › Section 510.4 - Expiration date

Current through Register Vol. 46, No. 28, July 10, 2024
The provisions of this Part shall expire on July 1, 1977
			   except as to those courses of treatment commenced before such expiration
			   date.
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 511 - Medical Care-utilization review › Section 511.1 - Utilization review

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In
			 accordance with section 365-g  of the Social Services Law, the department may
			 implement utilization reviews which apply to certain care, services, and
			 supplies for medical assistance (MA) recipients. Utilization review evaluates
			 the appropriateness and quality of medical assistance, and safeguards against
			 unnecessary utilization of care and services; including post-payment review
			 process to develop and review beneficiary utilization profiles, provider
			 services profiles and exceptions criteria to correct misutilization practice of
			 beneficiaries and providers; and for referral to the Office of the Medicaid
			 Inspector General where suspected fraud, waste or abuse are identified in the
			 unnecessary or inappropriate use of care, service or supplies.
(b) Within a benefit year, as defined in
			 section
			 511.4 
			 of this Part, the MA program will pay for care, services and supplies provided
			 to eligible recipients up to and including the number of service units
			 established as a utilization threshold for the particular provider service
			 type. A service unit is defined as one encounter, procedure, or formulary code,
			 depending upon the provider service type.
(c) After a recipient has reached the
			 utilization threshold established for a particular provider service type, the
			 MA program will not pay for additional care, services or supplies for that
			 provider service type unless one of the following conditions is satisfied:
(1) the department has exempted the recipient
			 from the utilization threshold;
(2)
			 the department has granted the recipient an increase in the utilization
			 threshold;
(3) the provider
			 certifies that the care, services, or supplies were furnished to address an
			 urgent medical need. An urgent medical need exists when a patient has an acute
			 or active medical problem which, if left untreated, could reasonably result in
			 an increase in the severity of the symptoms of the problem, an increase in the
			 patient's recovery time, or a medical emergency; or
(4) the provider certifies that the care,
			 services or supplies were furnished to address a medical emergency. Emergency
			 services are medical care, services or supplies provided after a sudden onset
			 of a medical condition manifesting itself by acute symptoms of sufficient
			 severity that the absence of immediate medical treatment could reasonably
			 result in serious impairment of bodily functions, serious dysfunction of a
			 bodily organ or body part, or would otherwise place the recipient's health in
			 serious jeopardy.
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 511 - Medical Care-utilization review › Section 511.2 - Notification to applicants and recipients (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.3 - Excluded services

Current through Register Vol. 46, No. 28, July 10, 2024
Utilization reviews do not apply to the following
			   services:
(a) services furnished by or
			 through a managed care program to persons enrolled in and receiving medical
			 care from such program. Managed care programs include health maintenance
			 organizations, preferred provider plans, physician case management programs or
			 other managed medical care programs recognized by the Department;
(b) services otherwise subject to prior
			 approval or prior authorization;
(c)
			 reproductive health and family planning services including: diagnosis,
			 treatment, drugs, supplies, and related counseling furnished or prescribed by a
			 physician or under a physician's supervision;
(d) until September 1, 1992, services
			 provided by or under the direction of a primary provider under the recipient
			 restriction program, as established by section
			 360-6.4  of this Title;
(e) methadone maintenance treatment
			 services;
(f) services provided by
			 private practitioners on a fee-for-service basis to inpatients in general
			 hospitals certified under Article 28 of the Public Health Law orArticle 31 of
			 the Mental Hygiene Law and residential health care facilities;
(g) hemodialysis services;
(h) obstetrical services provided by a
			 physician, hospital outpatient department, or free-standing diagnostic and
			 treatment center-certified under Article 28 of the Public Health Law;
			 or
(i) services provided through or
			 by referral from a preferred primary care provider designated pursuant to
			 Section 2807 (12)  of the Public Health Law;
(j) services provided pursuant to a court
			 order; or
(k) services provided as a
			 condition of eligibility for any other public program, including but not
			 limited to public assistance.
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 511 - Medical Care-utilization review › Section 511.4 - Benefit year; service units (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.5 - Applications for utilization threshold increases and exemptions (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.6 - Review of applications (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.7 - Additional service units pending determination of applications (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.8 - Determinations (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.9 - Fair hearings (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.10 - Physician and clinic services - utilization threshold (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.11 - Pharmacy services - utilization threshold (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.12 - Laboratory services - utilization threshold (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.13 - Mental health clinic programs-utilization threshold (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 511 - Medical Care-utilization review › Section 511.14 - Dental clinic services-utilization threshold (Repealed)

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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 512 - Drug Utilization Review › Section 512.1 - Scope, purpose and definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Scope. This Part sets forth the requirements and procedures for the
			 department's medical assistance (MA) prospective drug utilization review
			 program.
(b) Purpose. The purpose
			 of the program is to identify potential problems associated with MA recipient's
			 drug therapy. The problems which the program seeks to identify include, but are
			 not limited to, over-utilization, interactions between and among drugs
			 prescribed for an MA recipient, therapeutic overlap and other drug therapy
			 irregularities. Pharmacies which dispense drugs to MA recipients will have
			 access to a central computerized drug utilization review system which screens
			 ordered drugs against the recipient's drug history file for potential drug
			 therapy problems and informs the pharmacist of identified problems before the
			 pharmacist dispenses a drug. The pharmacist will be able to evaluate this
			 information and perform a prospective drug utilization review to determine
			 whether or not, in the pharmacist's professional judgement, therapeutic
			 intervention as described in section
			 512.4(d) 
			 of this Part is necessary.
(c)
			 Definitions. Terms used in this Part have the same meaning as those defined in
			 section
			 505.3  of this
			 Title unless otherwise specified.
(1)
			 Prospective drug utilization review means a pharmacist's analysis of an MA
			 recipient's drug use, based on established clinical standards for drug therapy,
			 which is done at the point of service before a drug is dispensed.
(2) Electronic Medicaid eligibility
			 verification system (EMEVS) means the department's on-line computerized system
			 for verification of an individual's eligibility for MA.
(3) National drug code (NDC) means the
			 numerical universal drug product code identifier which is assigned to a drug by
			 the Secretary of Health and Human Services pursuant to the Drug Listing Act of
			 1972 ( P.L. 92-387).
(4) Pharmacy
			 means any place meeting the definition contained in article 137 of the
			 Education Law and which is registered and licensed by the appropriate authority
			 of the state in which the pharmacy is located.
(5) Pharmacist means a person licensed or
			 otherwise authorized to practice pharmacy by the appropriate authority of the
			 state in which the pharmacist practices.
(6) Drug means both prescription and
			 nonprescription drugs.
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 512 - Drug Utilization Review › Section 512.2 - Requirements for pharmacies

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
			 pharmacy participating in the MA program is required to ensure that the
			 following minimum information concerning the drug or drugs which it is being
			 asked to dispense is entered into the EMEVS when an MA recipient, for whom MA
			 eligibility has been verified, presents an order for an out-patient drug or
			 drugs for which the pharmacy claims payment under the MA program:
(1) the NDC for the drug or drugs;
(2) the number of days for which the drug or
			 drugs will be supplied;
(3) the
			 date of the order; and
(4) the
			 ordering practitioner's Medicaid Management Information System (MMIS)
			 identification number, the practitioner's license number, or the certification
			 number of the facility in which the drugs were ordered.
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 512 - Drug Utilization Review › Section 512.3 - Payment to pharmacies

Current through Register Vol. 46, No. 28, July 10, 2024
Failure to follow the procedures set forth in section
			   512.2 
			   of this Part will result in denial of MA payment for those claims for which the
			   procedures were not followed.
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 512 - Drug Utilization Review › Section 512.4 - Use of prospective drug utilization review program data

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Information
			 which pharmacies provide through EMEVS will be stored for on-line retrieval and
			 other pharmacies will have access to the information.
(b) The department's use of information
			 obtained through the prospective drug utilization review program will include,
			 but need not be limited to, the following:
(1)
			 an analysis of an MA recipient's drug use patterns for post-payment audit
			 review purposes and potential recipient restriction action; and
(2) an analysis of drug ordering patterns by
			 MA providers for purposes of conducting MA provider audits and reviewing
			 quality control standards used by the provider.
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 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.0 - Policy, purpose and scope

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Policy. Where prior approval of medical, dental and remedial care, services or
			 supplies is required under the MA program, such prior approval will be granted
			 when the medical, dental and remedial care, services or supplies are shown to
			 be medically necessary to prevent, diagnose, correct or cure a condition of the
			 recipient which:
(1) causes acute
			 suffering;
(2) endangers
			 life;
(3) results in illness or
			 infirmity;
(4) interferes with the
			 capacity for normal activity; or
(5) threatens to cause a significant
			 handicap.
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 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.1 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
For purposes of this Part, the following terms have the
			   following meanings:
(a) Prior approval
			 means a determination by the Department of Health that medical, dental and
			 remedial care, services or supplies are medically necessary to prevent,
			 diagnose, correct or cure a condition of the recipient which:
(1) causes acute suffering;
(2) endangers life;
(3) results in illness or
			 infirmity;
(4) interferes with the
			 capacity for normal activity; or
(5) threatens to cause a significant
			 handicap.
Prior approval must be obtained for certain medical,
			   dental and remedial care, services or supplies before they are furnished or
			   payment cannot be made for them under the MA program.
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 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.2 - Procedure for obtaining prior approval

Current through Register Vol. 46, No. 28, July 10, 2024
(a) When prior approval of medical, dental
			 and remedial care is required, the potential provider must request such
			 approval from the Department of Health using the forms and procedures
			 prescribed by the Department of Health.
(b) The provider manuals of this department
			 detail the forms and procedures for obtaining prior approval. The manuals are
			 provided free of charge to every provider at the time of enrollment in the MA
			 program. Copies of the manuals may be obtained by writing Computer Sciences
			 Corporation, Health and Administrative Services Division, 800 N. Pearl St.,
			 Albany, NY 12204. Copies may also be obtained from the Department of Social
			 Services, 45 N. Pearl St., Albany, NY 12243.
(c) A recipient adversely affected by the
			 Department of Health's determination on a request may obtain a fair hearing
			 before an impartial hearing officer employed by this department in accordance
			 with section
			 513.8  of
			 this Part and Part 358 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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.3 - Obligations end responsibilities of recipients

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The recipient is responsible for
			 establishing that the medical, dental and remedial care, services or supplies
			 are medically necessary to prevent, diagnose, correct or cure a medical
			 condition and that any specific statutory or regulatory requirements for prior
			 approval of the care, services or supplies are met.
(b) The recipient is responsible for
			 providing all information, appropriate to the request, that the Department of
			 Health reasonably requires to evaluate a request, including detailed health
			 information and information concerning his or her education, training and
			 employment, activities of daily life, and current living
			 arrangements.
(c) The recipient
			 must cooperate with the Department of Health in obtaining information necessary
			 to evaluate a request. If the Department of Health determines that available
			 information is not sufficient to enable it to make an informed determination,
			 the recipient must submit to a clinical examination by an independent
			 practitioner under contract with the Department of Health or by a practitioner
			 employed or designated by the Department of Health.
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 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.4 - Obligations and responsibilities of the ordering practitioner and potential provider

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
			 ordering practitioner and the potential provider of the requested care,
			 services or supplies must assist the recipient in obtaining any information and
			 documentation necessary and appropriate to support a request, and provide all
			 such information, together with the request, to the Department of Health using
			 the forms and procedures prescribed by the Department of Health.
(b) The ordering practitioner is responsible
			 for verifying the recipient's eligibility for MA as of the date of the order
			 and certifying the medical necessity of the requested medical, dental and
			 remedial care, services or supplies. The potential provider is responsible for
			 verifying the recipient's eligibility for MA as of the date of the
			 request.
(c) The ordering
			 practitioner and potential provider are responsible for assuring that, in their
			 best professional judgment, the ordered and requested medical, dental and
			 remedial care, services or supplies will meet the recipient's medical needs;
			 reduce the recipient's physical or mental disability; restore the recipient to
			 his or her best possible functional level; or improve the recipient's capacity
			 for normal activity; and that they are necessary to prevent, diagnose, correct
			 or cure a condition in light of the recipient's specific circumstances and the
			 recipient's functional capacity to make use of the requested care, services or
			 supplies.
(d) The ordering
			 practitioner and potential provider are responsible for assuring that adequate
			 and less expensive alternatives have been explored and, where appropriate and
			 cost effective, are requested and that the medical, dental and remedial care,
			 services or supplies to be provided conform to accepted professional
			 standards.
(e) The ordering
			 practitioner and potential provider must cooperate with the Department of
			 Health in its evaluation of the request and take such actions as the Department
			 of Health may reasonably request to assure proper and timely evaluation of the
			 request.
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 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.5 - Obligations and responsibilities of the Department of Health

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The Department of Health must assist the
			 recipient in obtaining information and documentation in support of his or her
			 request from: providers who have treated the recipient; social services
			 district records; and other sources, including any information in the
			 recipient's case file or medical history, information from public or private
			 social welfare agencies, nonmedical sources, other practitioners and
			 observations by Department of Health and social services district
			 personnel.
(b) The Department of
			 Health may require a clinical examination of the recipient by an independent
			 practitioner under contract with or designated by the Department of Health to
			 obtain more detailed medical information, or technical or specialized
			 information about the recipient or the necessity of the care, service or
			 supplies to prevent, diagnose, correct or cure a condition in the recipient; or
			 to resolve conflicts or differences in medical or other information, or
			 assessments of the recipient's condition or needs.
(c) Since the ordering practitioner is the
			 preferred sources of information, the Department of Health must make all
			 reasonable efforts to obtain needed information from the ordering practitioner
			 before evaluating information obtained from other sources or requesting a
			 clinical examination. If the information provided by the ordering practitioner
			 is incomplete, the Department of Health must attempt to secure additional
			 information, interpretations or explanations from the ordering practitioner,
			 the treating practitioner and the potential provider before requesting a
			 clinical examination.
(d) The
			 Department of Health must give the recipient reasonable prior notice of any
			 required clinical examination, the date, time and place of the examination, and
			 the name and title of the person who will conduct the examination.
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 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.6 - Evaluation of requests

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Requests will be evaluated in accordance with:
(1) the specific statutory and regulatory
			 standards and benefit limits governing the furnishing of the requested care,
			 services or supplies;
(2) the
			 utilization control criteria promulgated by this department; and
(3) the medical necessity of the medical,
			 dental and remedial care, services or supplies to prevent, diagnose, correct or
			 cure a condition of the recipient which:
(i)
			 causes him or her acute suffering;
(ii) endangers his or her life;
(iii) results in his or her illness or
			 infirmity;
(iv) interferes with his
			 or her capacity for normal activity; or
(v) threatens him or her with a significant
			 handicap;
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 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.7 - Determinations

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The Department
			 of Health must issue a written determination approving, modifying or denying a
			 request within the time periods provided under section 85.37 of the Department
			 of Health regulations (10 NYCRR). If the determination modifies, or denies a
			 request, either in whole or in part, the written determination must set forth
			 the general nature of the request; the relevant facts; the applicable
			 guidelines, rules, regulations, and medical standards; and the reasons for
			 modifying or denying the request. However, if supporting factual, medical, or
			 other information is requested from the recipient, or the ordering or treating
			 practitioner or potential provider, or if a clinical examination is required,
			 the time to issue a determination is extended as provided in section 85.37 of
			 the Department of Health regulations (10 NYCRR).
(b) The determination must be based upon a
			 professional review by Department of Health personnel of clinical information
			 and opinion; factual, medical, and other relevant information submitted to, or
			 obtained by, the Department of Health; the written guidelines of the Department
			 of Health; the regulations of this department; and commonly accepted medical
			 practice.
(c) A copy of the written
			 determination denying or modifying the request, including a formal notice of
			 hearing rights which meets the requirements of Part 358 of this Title, must be
			 sent to the recipient within the time period specified in subdivision (a) of
			 this section.
(d) If the requested
			 medical, dental and remedial care, services or supplies are otherwise available
			 under the MA program and there is no clinical information or documentation
			 conflicting with the opinion of the ordering or treating practitioner, the
			 Department of Health must approve the request as submitted.
(e) If the recipient does not appear for a
			 clinical examination as required by the Department of Health, or in accordance
			 with prior alternative arrangements made with the recipient, the Department of
			 Health may deny the request.
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 513 - Prior Approval Of Medical, Dental And Remedial Care › Section 513.8 - Fair hearings

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
			 recipient may ask for a fair hearing from this department to review a denial or
			 modification of a request or the failure of the Department of Health to make a
			 determination within the time period specified in this Part. The method for
			 asking for the hearing and the procedures for the conduct of the hearing are
			 governed by Part 358 of this Title.
(b) A fair hearing held pursuant to this
			 section is limited to a review of the following issues:
(1) whether the requested medical, dental and
			 remedial care, services or supplies are medically necessary and appropriate for
			 the individual recipient's medical needs;
(2) whether other adequate and less expensive
			 alternatives have been explored and, where appropriate and cost effective, were
			 authorized;
(3) whether the medical
			 or dental care, services or supplies requested or authorized conform to
			 accepted professional standards;
(4) whether the Department of Health failed
			 to make a determination within the time period specified in this Part;
			 and
(5) whether the recipient and
			 the Department of Health complied with the processes and procedures of this
			 Part and Part 358 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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 514 - Provider Verification Of Recipient Eligibility And Orders For Service › Section 514.1 - Policy

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In order to
			 avoid unnecessary processing of medical assistance (MA) claims, administrative
			 expense to the MA program, provider billing errors resulting in nonpayment of
			 claims and to reduce unacceptable provider practices, the department may
			 require a provider to verify MA recipient eligibility. The department may also
			 require a provider to verify orders for care, services or supplies.
(b) A provider required to do so must verify
			 MA recipient eligibility by making an inquiry to an electronic data system
			 prior to furnishing any item of care, services or supplies for which payment
			 will be claimed under the MA program. A provider required to do so must make an
			 inquiry to an electronic data system to determine whether an order for care,
			 services or supplies has been posted in the electronic data system by the
			 ordering provider and is therefore subject to reimbursement if filled by the
			 inquiring provider.
(c) The
			 department may require a provider to verify recipient eligibility if the
			 department determines that the provider engages in a significant number or MA
			 transactions, or the provider's service profile exceeds the department's
			 utilization control criteria. The department may require a provider to verify
			 orders for care, services or supplies if the provider engages in a significant
			 number of MA transactions, or the provider's service profile exceeds the
			 department's utilization control criteria, or other circumstances warrant
			 imposition of this control to assure validity of orders for care, services or
			 supplies.
(d) A provider required
			 to verify recipient eligibility or orders for care, services or supplies who
			 fails to verify properly may have payment for claims under the MA program
			 withheld or denied or be subject to sanctions, as defined in Part 515 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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 514 - Provider Verification Of Recipient Eligibility And Orders For Service › Section 514.2 - Introduction

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The department
			 has established an electronic eligibility verification system whereby a
			 provider may determine the eligibility status of any person seeking care,
			 services or supplies under the MA program before furnishing care, services or
			 supplies to such person.
(b) The
			 system was designed to assure that a provider can verify the current MA
			 eligibility of persons seeking medical or dental care, services or supplies
			 and, thus, be assured that legitimate claims submitted to the department for
			 services rendered to eligible recipients will be paid.
(c) If, on the date of service, the provider
			 verifies eligibility in accordance with the verification procedures of this
			 Part, payment will not be denied because the recipient was not MA eligible on
			 the date that the care, services or supplies were furnished.
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 514 - Provider Verification Of Recipient Eligibility And Orders For Service › Section 514.3 - Electronic eligibility verification system

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The department's electronic Medicaid
			 eligibility verification system is known as EMEVS. Recipient eligibility may be
			 verified by accessing EMEVS through a Medicaid eligibility terminal (MET) or by
			 telephone. The procedures for verifying eligibility through the MET or by
			 telephone are fully explained in the department's publication "New York State
			 Electronic Medicaid Verification System Provider Manual". The publication is
			 available by writing to the following office:
Electronic Medicaid Eligibility Verification
			   System
Department of Social Services
40 N. Pearl Street
Albany, NY 12243
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 514 - Provider Verification Of Recipient Eligibility And Orders For Service › Section 514.4 - Medicaid eligibility terminal (MET)

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The MET is an electronic device which
			 permits a provider to verify MA recipient eligibility immediately through
			 EMEVS. Any provider who establishes a need to the department's satisfaction may
			 request the department to provide a MET.
(b) The department may require a provider to
			 verify MA recipient eligibility by using a MET if the department determines
			 that the provider's claims or orders for MA care, services or supplies meet or
			 exceed one or more of the criteria set forth below:
(1) the dollar value of claims submitted or
			 care, services or supplies ordered by the provider for the prior 12 month
			 period exceeds $75,000; or
(2) the
			 dollar value of claims submitted or care, services or supplies ordered by the
			 provider for a weekly period, when projected to a yearly period, will exceed
			 $75,000; or
(3) the number of
			 claims submitted by the provider or amount paid to the provider for a quarterly
			 period places the provider in the upper quartile of a rank order listing of
			 billers in the applicable provider type; or
(4) the claims submitted by the provider
			 indicate frequent, repetitive encounters with recipients or repetitive
			 dispensing patterns; or
(5) the
			 claims submitted by the provider for a weekly period indicate an increase of 10
			 percent or more in total amount billed, average cost per claim or average cost
			 per recipient encounter from the previous quarter; or
(6) the claims submitted by the provider for
			 a quarterly period exceed by two standard deviations or more the average number
			 of claims per recipient encounter submitted or average dollar value of claims
			 per recipient encounter submitted by billers in the applicable provider
			 type.
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 514 - Provider Verification Of Recipient Eligibility And Orders For Service › Section 514.5 - Card swipe

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The MA
			 recipient identification card is a plastic card which can withstand repeated
			 use. This card, with or without a photograph of the recipient, is the card most
			 commonly used by the MA program throughout the State.
(b) The plastic identification card has a
			 magnetic strip on the reverse side containing encoded information which is read
			 by the MET.
(c) If the department
			 requires a provider to use a MET, the provider is also required to insert the
			 recipient's plastic card into the MET and "swipe" the card through the terminal
			 in order that the MET may read the encoded information.
(d) If the card swipe capability is not
			 functioning or if the recipient does not have a plastic identification card
			 (e.g., the recipient has a temporary MA identification card or replacement
			 card), the provider must manually enter the recipient information into the MET
			 or use the alternative telephone verification procedure provided for in
			 conjunction with EMEVS to verify eligibility.
(e) If a provider who is required to use a
			 MET does not use the card swipe capability of the MET in a significant number
			 of its weekly MA transactions, the department may withhold payment of claims
			 equivalent in dollar value to the percentage of claims in such weekly
			 transaction period with respect to which the provider failed to use the card
			 swipe capability pending an audit or review of the claims submitted and the
			 provider's service and claiming practices. If the department finds a
			 significant number of unjustified failures by the provider to use the card
			 swipe capability, the department may treat such provider failures as an
			 unacceptable practice under Part 515 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 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 514 - Provider Verification Of Recipient Eligibility And Orders For Service › Section 514.6 - Posting of orders for care, services or supplies

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In certain instances, as defined by Parts
			 505 and 506 of this Title, a prescription or fiscal order is required before a
			 provider may furnish MA care, services or supplies (e.g., provision of
			 laboratory services, drugs or sickroom supplies requires the fiscal order of a
			 qualified practitioner). With regard to care, services or supplies for which a
			 prescription or fiscal order is required, the department may direct an ordering
			 provider to enter an authorization into EMEVS ("posting") for the ordered care.
			 Services or supplies which are to be furnished by another provider if the
			 department determines that the ordering provider's claims or orders for MA
			 care, services or supplies satisfy one or more of the criteria set forth in
			 section
			 514.4(b) 
			 of this Part.
(b) Posting of the
			 order in EMEVS by the ordering provider establishes a record that the care,
			 services or supplies have been ordered by a qualified provider. The posting
			 process enables the department to verify that the care, services or supplies
			 have been properly ordered before paying a provider who submits a claim for
			 furnishing them. Posting also permits the provider who is requested to furnish
			 ordered care, services or supplies to verify through inquiry to EMEVS that the
			 care, services or supplies have been properly ordered before filling the order.
			 The provider manual addressing the particular care, services or supplies
			 ordered sets forth in detail those service types or procedures requiring
			 written orders.
(c) If an ordering
			 provider who is required to post fails to post properly in a significant number
			 of its weekly MA transactions, the department may withhold payment of claims
			 submitted by the ordering provider which are equivalent in dollar value to
			 established MA reimbursement amounts for care, services or supplies rendered or
			 furnished by the ordering provider to an MA recipient on the same date of
			 service within the weekly transaction period as care, services or supplies
			 ordered for such recipient with respect to which the ordering provider failed
			 to post properly, pending an audit or review of claims submitted and the
			 ordering provider's service and claiming practices. If the department finds a
			 significant number of unjustified failures by the provider to post orders, the
			 department may treat such provider failures as an unacceptable practice under
			 Part 515 of this Title.