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 2 - Program Administration › Part 504 - Medical Care-enrollment Of Providers › Section 504.6 - Acceptance of an application

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Upon
			 acceptance of an application, the department shall issue to the provider
			 instructions on participation in the medical assistance program and filing of
			 claims for payment. In addition, the provider shall be given an identifying
			 number to be used exclusively by the provider for billing and identification
			 purposes.
(b) Enrollment, including
			 the use of the identifying number, is not assignable or transferrable but is
			 strictly limited to the provider to which it was issued unless authorized in
			 writing by the department 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
			 under this Title.
(d) A provider
			 may submit claims only for services provided by the provider or another person
			 under his supervision and in compliance with this Title; the name of the person
			 actually furnishing the care, services or supplies shall be indicated on the
			 claim form in the space provided.
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 2 - Program Administration › Part 504 - Medical Care-enrollment Of Providers › Section 504.7 - 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 either the provider or the department upon 30 days'
			 written notice to the other without cause.
(b) A provider's participation in the program
			 may be terminated, suspended or restricted for a reasonable period of time if
			 the department finds that the provider has engaged in an unacceptable practice
			 as set forth in Part 515 of this Title. A provider whose participation is so
			 terminated, suspended or restricted is entitled to notice and an opportunity to
			 be heard in accordance with Part 515 of this Title.
(c) A provider's participation is
			 automatically terminated or suspended as of the date of the provider's
			 suspension or termination from Medicare. A notice confirming the termination or
			 suspension will be sent to the provider.
(d)
(1) A
			 provider's participation in the medical assistance program is automatically
			 terminated as of the date of any termination, revocation or suspension of a
			 license to practice a medical profession, or the termination, revocation or
			 suspension of any registration, certification, license or other approval
			 required to provide medical care, services or supplies under the medical
			 assistance program. However, a provider of intermediate care facility services
			 for the developmentally disabled, licensed or operated by the Office of Mental
			 Retardation and Developmental Disabilities, whose participation in the medical
			 assistance program is terminated by the department because the provider no
			 longer meets the requirements for participation or whose participation in such
			 program is not renewed upon expiration of its provider agreement with the
			 department, remains eligible to participate in the program if the Department of
			 Health certifies that the provider's continuation in the medical assistance
			 program will not jeopardize a medical assistance recipient's health and safety
			 and the provider has requested an administrative evidentiary hearing which is
			 held after the effective date of termination or nonrenewal or is held before
			 such date but not completed until after such date.
(2) A provider who is permitted to remain in
			 the medical assistance program as a result of meeting the conditions of
			 continuation, as set forth in paragraph (1) of this subdivision, may remain in
			 the program until the earlier of:
(i) the
			 date that an administrative hearing decision is issued in the evidentiary
			 hearing which upholds the department's termination or nonrenewal action;
			 or
(ii) the 120th day after the
			 effective date of termination of the facility's provider agreement or, if the
			 agreement is not terminated, the 120th day after the effective date of
			 expiration.
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 2 - Program Administration › Part 504 - Medical Care-enrollment Of Providers › Section 504.8 - Audit and claim review

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Providers
			 shall be subject to audit by the department and with respect to such audits
			 will be required:
(1) to reimburse the
			 department for overpayments discovered by audits in accordance with Parts 516
			 and 517 of this Title;
(2) to pay
			 restitution for any direct or indirect monetary damage to the program resulting
			 from their improperly or inappropriately furnishing services or arranging for,
			 ordering, or prescribing care, services or supplies, in accordance with Parts
			 515 and 516 of this Title;
(3) to
			 reimburse the auditing agency for the costs incurred by the department in
			 performing the audit where records are not maintained in a readily reviewable
			 form; and
(4) to pay any
			 statutorily authorized fine or penalty.
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 2 - Program Administration › Part 504 - Medical Care-enrollment Of Providers › Section 504.9 - Service bureaus, billing services and electronic media billers

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
(1)
			 Persons submitting claims, verifying client eligibility or obtaining service
			 authorizations for or on behalf of providers, except those individuals employed
			 by providers enrolled in the medical assistance program, must enroll in the
			 medical assistance program in accordance with this Part and must meet the
			 appropriate additional requirements set forth in this section. However, payment
			 may be made only to the provider of the medical care, services or supplies; or
			 in accordance with a reassignment from a provider to a government agency or
			 reassignment by court order; or to an employer of a practitioner, if the
			 practitioner is required as a condition of his/her employment to turn over
			 his/her fees to the employer; or to a facility or a foundation, plan or similar
			 organization operating an organized health care delivery system, if the
			 practitioner has a contract under which the facility or organization submits
			 the claims; or to a business agent, including a service bureau, billing
			 service, or accounting firm, if the payment is made in the name of the provider
			 and the agent's compensation for the services is related to the cost of
			 processing the claim, is not related on a percentage or other basis to the
			 amount billed or collected, and is not dependent upon collection of the
			 payment.
(2) Providers submitting
			 their claims by means of electronic/magnetic media (computer tape, disks, etc.)
			 must also meet the requirements of this section in order to be eligible to
			 submit their claims by such media.
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 2 - Program Administration › Part 504 - Medical Care-enrollment Of Providers › Section 504.10 - New enrollments; previously enrolled providers

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Any person wishing to participate as a
			 provider on or after the effective date of this Part [January 5, 1987] will be
			 required to submit an application for enrollment in accordance with the
			 requirements of this Part.
(b) All
			 providers enrolled prior to the effective date of this Part [January 5, 1987]
			 shall be required to submit an application for enrollment upon notice from the
			 department. A provider so notified will have 60 days to submit a completed,
			 signed enrollment application to the department. The failure to do so will
			 result in the provider's automatic termination from the medical assistance
			 program. Written notice of the termination will be sent to the provider.
			 Submission of the application within 60 days will continue the provider's
			 enrollment until a determination with respect to the application for enrollment
			 has been made and notice thereof mailed to the provider.
(c) For the convenience of the department and
			 the provider community, providers enrolled prior to the effective date of this
			 Part [January 5, 1987] shall be notified of the requirement to reenroll
			 pursuant to subdivision (b) of this section in accordance with a reenrollment
			 schedule developed by the department. Such schedule may require reenrollment on
			 the basis of provider type, geographic location or a combination of provider
			 type and location.
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 2 - Program Administration › Part 504 - Medical Care-enrollment Of Providers › Section 504.11 - Financial security

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 General.
(1) Purpose. The furnishing of
			 financial security will indemnify the department against overpayments which may
			 be made to the provider.
(2) This
			 section applies only to providers of ordered services or supplies and
			 applicants for enrollment as providers of such services or supplies. For the
			 purposes of this section, ordered services or supplies are:
(i) pharmacy services and supplies;
(ii) durable medical equipment;
(iii) clinical laboratory services;
			 and
(iv) nonemergency
			 transportation.
(3) The
			 department may require a provider to provide financial security to the
			 department if the department has estimated that the total claims for payment
			 for ordered services or supplies to be submitted to the department by that
			 provider exceed either $500,000 per year or $42,000 in any month. The
			 computation of these estimates must exclude the amount, if any, of the estimate
			 of the provider's claims for payment for services that are not ordered
			 services. When the department has determined that a provider must furnish
			 financial security, that provider must provide such security as a condition of
			 the provider's participation or continued participation in the medical
			 assistance 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 505 - Charges For Professional Health Services › Section 505.1 - Scope of medical assistance

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Services available.
(1) Medical care,
			 services and supplies available to eligible persons must, except to the extent
			 that such medical care, services and supplies are certified as inappropriate,
			 unnecessary or otherwise not authorized by the Commissioner of Health or his or
			 her designee and except as provided in subdivision (b) of this section, include
			 the following:
(i) services of qualified
			 physicians, dentists, nurses, optometrists and other related professional
			 personnel;
(ii) care, treatment,
			 maintenance and nursing services in hospitals, skilled nursing facilities that
			 qualify as, or have applications pending to become, providers in the Medicare
			 program pursuant to title XVIII of the Federal Social Security Act, or other
			 eligible institutions, and health- related care and services in intermediate
			 care facilities, while such institutions and facilities are operated in
			 compliance with applicable provisions of law and to the extent authorized by
			 this Subchapter. However, no medical assistance payment will be authorized for
			 care provided after December 31, 1977 in skilled nursing facilities which have
			 participated in title XIX since September 1, 1976, but for whom title XVIII
			 certification is still lacking, except for those skilled nursing facilities
			 providing solely pediatric care;
(iii) services to ensure improved outcomes of
			 women ages 21 through 44 experiencing infertility, limited to ovulation
			 enhancing drugs, office visits, hysterosalpingogram services, pelvic
			 ultrasounds, and blood testing.
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 505 - Charges For Professional Health Services › Section 505.3 - Drugs

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Definitions.
(1)
Compounded prescription
means one in which two or more
			 ingredients are mixed by the dispensing pharmacist. Medical assistance
			 reimbursement for compounding is limited to the following:
(i) a combination of any two or more legend
			 drugs found on the list of Medicaid reimbursable prescription drugs;
			 or
(ii) a combination of any legend
			 drugs included on the list of Medicaid reimbursable prescription drugs and any
			 other item(s) not commercially available as an ethical or proprietary
			 product(s); or
(iii) a combination
			 of two or more products which are labeled "Caution: For Manufacturing Purposes
			 only." The reconstitution of a commercially available drug is not a compounded
			 prescription.
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 505 - Charges For Professional Health Services › Section 505.4 - Hospital services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Definition. Inpatient hospital care shall include, except as otherwise
			 specified, the care, treatment, maintenance and nursing services as may be
			 required on an inpatient basis and certified to be covered by the Commissioner
			 of Health or his designee under the regulations of the State Department of
			 Health.
(b) Exclusions.
(1) Care, treatment, maintenance and nursing
			 services for individuals admitted to a general hospital on Friday or Saturday
			 shall be deemed to include only those inpatient days beginning with and
			 following the Sunday after such date of such admission unless such periods of
			 time are determined to be covered benefits pursuant to Part 85 of Department of
			 Health's regulations or are rendered by general hospitals determined by the
			 Commissioner of Health to be rendering full service on a seven-day-a-week
			 basis.
(2) Care, treatment,
			 maintenance and nursing services for uncomplicated procedures which may be
			 performed on an outpatient basis in accordance with regulations issued by the
			 Commissioner of Health, unless the Commissioner of Health or his designee
			 determines that the medical condition of the individual patient requires that
			 the procedure be performed on an in-patient basis.
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 505 - Charges For Professional Health Services › Section 505.5 - Durable medical equipment; medical/surgical supplies; orthotic and prosthetic appliances; orthopedic footwear

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Definitions.
(1) Durable medical equipment means devices
			 and equipment, other than prosthetic or orthotic appliances, which have been
			 ordered by a practitioner in the treatment of a specific medical condition and
			 which have all of the following characteristics:
(i) can withstand repeated use for a
			 protracted period of time;
(ii) are
			 primarily and customarily used for medical purposes;
(iii) are generally not useful to a person in
			 the absence of an illness or injury; and
(iv) are usually not fitted, designed or
			 fashioned for a particular individual's use. Where equipment is intended for
			 use by only one person, it may be either custom-made or customized.
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 505 - Charges For Professional Health Services › Section 505.6 - Ophthalmic services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Definitions.
(1)
Qualified optometrist
shall mean an optometrist who is
			 licensed and currently registered by the New York State Education Department
			 or, if in practice in another state, by the appropriate agency of that
			 state.
(2)
A qualified
			 dispenser
shall mean an ophthalmic dispenser who is licensed and
			 currently registered by the New York State Department of Education or, if in
			 practice in another state by the appropriate agency of that state.
(3)
Low vision
shall mean
			 20/70 or less in the best eye with best correction.
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 505 - Charges For Professional Health Services › Section 505.7 - Laboratory services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Scope
			 of services. This section sets forth the requirements and procedures for
			 furnishing laboratory services and obtaining payment for laboratory services
			 under the medical assistance (MA) program. Payment for laboratory services is
			 limited to those medically necessary tests and procedures listed in the MA fee
			 schedule for laboratory services. The MA fee schedule for laboratory services
			 is available from the Department and may also be found in the Medicaid
			 Management Information System (MMIS) Provider Manual (Laboratory), which is
			 available by writing Computer Sciences Corporation, Health and Administrative
			 Services Division, 800 North Pearl Street, Albany, NY 12204. Copies may also be
			 obtained from the Department of Social Services, 40 North Pearl Street, Albany,
			 NY 12243. The manual is provided free of charge to every laboratory upon
			 enrollment in the MA program. Revisions to the manual are provided to
			 laboratories as revisions are made.
(b) Definitions.
(1)
(i)
			 Fiscal order for laboratory services means a qualified practitioner's
			 authenticated request to a clinical laboratory for the provision of a test,
			 examination and/or analysis on behalf of a recipient of MA. Authentication of
			 fiscal orders shall be by a qualified practitioner or by designation as
			 provided in subdivision (i) of this section and shall consist of either:
(a) handwritten signature of name or
			 initials; or
(b) electronic or
			 computer-generated signature of name or unique identifier acceptable to the
			 department.
All orders must show the ordering practitioner's: name,
			   address, telephone number, and MMIS provider identification number (or license
			   number of the ordering practitioner when such practitioner is not an enrolled
			   MA provider); and the name, date of birth, sex and MA identification number of
			   the recipient for whom services are ordered. The order must also contain at
			   least the date the test was ordered and the name of the test. The order must
			   meet any applicable New York State and Federal requirements governing the
			   ordering of laboratory services. The ordering practitioner must document in the
			   patient's clinical record the medical need for the fiscal order and the results
			   of each of the tests.
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 505 - Charges For Professional Health Services › Section 505.8 - Nursing service

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Where
			 nursing care may be provided. Nursing services, as medically needed, may be
			 provided to a medical assistance recipient in the person's home and, with
			 respect to a child receiving nursing services pursuant to an individualized
			 education program or an interim or final individualized family services plan,
			 also in a school, an approved pre-school or a natural environment, including
			 home and community settings, where such child would otherwise be
			 found.
(b) Who may provide nursing
			 care.
(1) Nursing care to patients in New
			 York State shall be provided by a person possessing a license and current
			 registration from the New York State Education Department to practice as a
			 registered professional nurse or licensed practical nurse.
(2) Out-of-state nurses providing care to a
			 New York State Medical Assistance patient who is temporarily located outside
			 New York State, must be licensed and registered in the state in which they are
			 practicing.
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 505 - Charges For Professional Health Services › Section 505.9 - Residential health care

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Qualifications for participation.
(1) In-state nursing facility care. Nursing
			 care must be provided only in a nursing facility, as defined in the regulations
			 of the Department of Health, which:
(i) holds
			 a current operating certificate issued by the Department of Health;
(ii) qualifies as, or has an application
			 pending to become, a provider in the Medicare program pursuant to title XVIII
			 of the Federal Social Security Act, unless the nursing facility provides care
			 solely to pediatric patients;
(iii)
			 meets the Federal requirements for a "nursing facility" under title XIX of the
			 Federal Social Security Act; and
(iv) has a current effective provider
			 agreement with the Department of Social Services.
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 505 - Charges For Professional Health Services › Section 505.12 - Podiatry services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Qualified podiatrist.
(1) A podiatrist
			 providing services under the medical assistance program shall be licensed by
			 and currently registered to practice podiatry in New York State with the State
			 Education Department.
(2) Podiatry
			 services provided to eligible medical assistance patients while temporarily
			 out-of-state shall be provided by podiatrists qualified to practice podiatry by
			 the appropriate licensing agency of the state in which podiatry services are
			 provided.
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 505 - Charges For Professional Health Services › Section 505.13 - Family planning

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Definitions.
(1)
Family
			 planning services
mean the offering, arranging and furnishing of those
			 health services which enable individuals, including minors who may be sexually
			 active, to prevent or reduce the incidence of unwanted pregnancies. Such
			 services include professional medical counseling services, prescription drugs,
			 nonprescription drugs and medical supplies prescribed by a qualified physician,
			 nurse practitioner or physician's assistants, and sterilization. Family
			 planning services do not include hysterectomy procedures.
(2)
Offering of and arranging for
			 family planning
means providing services under the medical assistance
			 program such as:
(i) disseminating
			 information, either orally or in writing, about available family planning
			 health services;
(ii) providing for
			 individual or group discussions regarding family planning health services;
			 and
(iii) providing assistance with
			 arranging visits with medical family planning providers.
(3)
Sterilization
means any
			 medical procedure, treatment or operation for the purpose of rendering an
			 individual permanently incapable of having children.
(4)
Hysterectomy
means a
			 medical procedure or operation for the purpose of removing the
			 uterus.
(5)
Medical family
			 planning provider
means physicians qualified to participate in the
			 medical assistance program, qualified nurse-midwives, hospitals, hospital
			 out-patient departments, diagnostic and treatment centers and health
			 maintenance organizations operated in compliance with applicable provisions of
			 law.
(6)
Nonmedical family
			 planning provider
means persons or facilities, not otherwise eligible
			 to enroll as a Medicaid provider, with whom a local social services district
			 contracts to offer and arrange family planning services under the medical
			 assistance program, title XIX of the Social Security Act.
(7)
A mentally incompetent
			 individual
means an individual who has been declared mentally
			 incompetent for any purpose by a Federal, State or local court of competent
			 jurisdiction, unless the individual has been declared competent for purposes
			 which include the ability to consent to sterilization.
(8)
An institutionalized
			 individual
means an individual who is involuntarily confined or
			 detained, under a civil or criminal statute, in a correctional or
			 rehabilitative facility including a mental hospital or other facility for the
			 care and treatment of mental illness; or, confined under a voluntary
			 commitment, in a mental hospital or other facility for the care and treatment
			 of mental illness.
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 505 - Charges For Professional Health Services › Section 505.15 - Psychiatric care

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Provision of
			 psychiatric care by psychiatrists in private practice.
(1) Psychiatric care may be provided to a
			 recipient of medical assistance by a qualified psychiatrist in the
			 psychiatrist's office; in the recipient's home; in a clinic, a general or
			 chronic disease hospital or approved medical institution or facility operated
			 in compliance with applicable provisions of law; with respect to a child
			 receiving psychiatric care pursuant to an individualized education program,
			 such care may be provided in a school or an approved pre-school; or, for
			 persons aged 65 and over and for those under 21 years of age, such care may be
			 provided in a hospital caring exclusively or primarily for persons with mental
			 disease. In the case of a recipient who during the course of hospitalization
			 attains the age of 21, such services may continue until he or she reaches the
			 age of 22.
(2) In the delivery of
			 psychiatric care, a qualified psychiatrist in private practice may employ up to
			 four certified social workers to provide care under his continuing direct
			 supervision as part of a course of treatment. Services rendered by a social
			 worker shall conform with the provisions of section 85.32 of the regulations of
			 the New York State Department of Health. For purposes of this section, a
			 certified social worker rendering services under the Medical Assistance Program
			 shall mean a social worker certified pursuant to the New York State Education
			 Law, and evidence of current registration under such law shall be provided upon
			 request of the Department of Social Services.
(3) Psychiatric care furnished to a child
			 which is part of the development of, or pursuant to, an individualized
			 education program may be provided by a psychiatrist, certified social worker or
			 certified school social worker employed by, or under contract to, a school
			 district, an approved pre-school, or a county in the State or the city of New
			 York. For purposes of this section, a certified school social worker means a
			 school social worker currently registered and certified in accordance with the
			 New York State Education Law and the rules of the Commissioner of
			 Education.
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 505 - Charges For Professional Health Services › Section 505.16 - Case management

Current through Register Vol. 46, No. 28, July 10, 2024
Medical assistance includes case management services
			   furnished in accordance with the provisions of this section.
(a) Definitions.
(1) Case management is a process which
			 assists persons eligible for medical assistance to access necessary services in
			 accordance with goals contained in a written case management plan.
(2) Case management services:
(i) are those services which will assist
			 persons eligible for medical assistance to obtain needed medical, social,
			 psychosocial, educational, financial and other services; and
(ii) are meant to assist persons identified
			 as high users of services, or as having problems accessing medical care or
			 services, or as belonging to certain age, diagnostic or specialized program
			 groups, on a statewide basis or limited to persons residing in definable
			 geographic areas.
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 505 - Charges For Professional Health Services › Section 505.17 - Radiology services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Scope.
			 This section describes the department's policies governing the provision of and
			 payment for radiology services under the medical assistance (MA)
			 program.
(b) Purpose. The MA
			 program will pay for medically necessary radiology services provided by
			 qualified practitioners as described in this section and in the settings
			 authorized by this section.
(c)
			 Definitions.
(1) Dentist means a dentist who
			 is qualified in accordance with Part 506 of this Title.
(2) Physician nonspecialist means a physician
			 who is qualified in accordance with section
			 505.2  of
			 this Part.
(3) Physician specialist
			 means a physician, other than a radiologist, who is qualified as a specialist
			 in accordance with section
			 505.2  of
			 this Part.
(4) Podiatrist means a
			 podiatrist who is qualified in accordance with section
			 505.12  of this
			 Part.
(5) Qualified practitioner
			 means a radiologist, physician specialist, physician nonspecialist, dentist or
			 podiatrist as defined in this section.
(6) Radiologist means a physician who is
			 qualified as a specialist in radiology in accordance with section
			 505.2  of
			 this Part.
(7) Radiology services
			 means the provision of the following services to MA recipients:
(i) interventional radiology;
(ii) screening and diagnostic radiology,
			 including ultrasound and nuclear medicine; or
(iii) radiation oncology.
(8) Mobile setting means those radiology
			 services provided by a qualified practitioner which are not performed in the
			 practitioner's office and includes those services which use portable equipment
			 for the provision of radiology services.
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 505 - Charges For Professional Health Services › Section 505.18 - Clinical psychological services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) General. Clinical psychological service
			 shall be made available to persons eligible for medical assistance as part of
			 comprehensive health care. Such services include psychological evaluation and
			 various therapeutic procedures appropriate for the given personality or
			 behavior disorder. All services provided shall adhere to standards of good and
			 proper practice acceptable to the State Commissioner of Health as set forth in
			 section 98-a of the rules of the Commissioner of Education and in the code of
			 ethics of the New York State Psychological Association.
(b) Qualifications.
(1) Basic requirements. Psychological
			 services shall be provided by psychologists who are qualified as clinical
			 psychologists in accordance with the following criteria:
(i) certification in accordance with article
			 153 of the New York State Education Law;
(ii) completion of at least three years of
			 training or supervised experience in clinical psychology in addition to the
			 education requirements for certification, and is engaged in professional
			 practice, at least half of which is devoted to providing clinical psychological
			 services.
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 505 - Charges For Professional Health Services › Section 505.19 - Standards for services rendered by physicians' assistants and specialists' assistants

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Services rendered by a registered physician's assistant or registered
			 specialist's assistant shall conform to requirements in articles 131B and 37,
			 respectively, of the State Education and Public Health Laws and to applicable
			 provisions in regulations of the New York State Department of Health.
(b) Services so provided shall be eligible
			 for payment from medical assistance funds as follows:
(1) To the physician employing the registered
			 physician's assistant or registered specialist's assistant. Such payments shall
			 be reimbursable at fees established for physicians in Part 533 of this Title.
(i) Maximum reimbursable fee allowances
			 contained in Part 533 of this Title shall apply whether the service is provided
			 directly by the physician alone, by his employed physician's assistant or
			 specialist's assistant, or by the combined service of both the physician and
			 his employed physician's assistant or specialist's assistant.
(ii) No duplication or increase in charges
			 shall be made by the physician for a listed service or procedure because of the
			 use of or assistance provided by a physician's assistant or specialist's
			 assistant in his employ.
(iii) A
			 physician's claim for payment shall include identification of those services or
			 procedures for which fees have been established which have been rendered by his
			 employed physician's assistant or specialist's assistant and also the name of
			 the physician's assistant or specialist's assistant who rendered the
			 care.
New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 505 - Charges For Professional Health Services › Section 505.21 - Long term home health care programs; AIDS home care programs

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Definitions.
(1) Long term home health care program
			 (LTHHCP) means a coordinated plan of care and services provided at home to
			 invalid, infirm or disabled persons who are medically eligible for placement
			 for an extended period of time in a hospital or residential health care
			 facility (RHCF) if the LTHHCP were unavailable. Such program can be provided in
			 the person's home, including an adult care facility other than a shelter for
			 adults, or in the home of a responsible relative or other responsible
			 adult.
(2)
(i) AIDS home care program (AHCP) means a
			 coordinated plan of care and services provided at home to persons who are
			 medically eligible for placement in a hospital or an RHCF and who are diagnosed
			 by a physician as having acquired immune deficiency syndrome (AIDS) or human
			 immunodeficiency virus (HIV)-related illness as defined by the AIDS Institute
			 of the State Department of Health. Such definitions are contained in directives
			 issued by the department from time to time.
(ii) An AHCP can be provided only by a LTHHCP
			 provider specifically authorized under article 36 of the Public Health Law to
			 provide an AHCP as a discrete part of the LTHHCP.
(iii) An AHCP can be provided in the person's
			 home, which includes an adult care facility specifically approved to admit or
			 retain residents for such program, the home of a responsible relative or other
			 responsible adult, or in other residential settings as approved by the
			 Commissioner of Health in conjunction with the Commissioner of Social
			 Services.
(3) Government
			 funds means funds provided under the provisions of title 11 of article 5 of the
			 Social Services Law (medical assistance to needy persons).
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 505 - Charges For Professional Health Services › Section 505.22 - Shared health facilities

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
			 shared health facility means any arrangement or operation for the delivery of
			 medical or health care, or services meeting the criteria set forth in
			 subdivision 2 of section 4702  of the Public Health Law, as
			 implemented by appropriate sections of 10 NYCRR Part 83 (regulations of the
			 State Department of Health).
(b)
			 Effective September 1, 1977, providers and purveyors who engage in any
			 arrangement or operation for the delivery of medical or health care or services
			 in facilities which have been determined by the State Department of Health,
			 pursuant to the provisions of article 47 of the Public Health Law or 10 NYCRR
			 Part 83, to be a shared health facility will be reimbursed only if that shared
			 health facility is currently registered with the State Department of
			 Health.
(c) Effective September 1,
			 1977, shared health facilities participating in the medical assistance program
			 shall be operated in compliance with 10 NYCRR Part 83.
(d) In addition to the applicable billing
			 requirements set forth in section
			 540.7  of
			 this Title, each provider and purveyor who provides services in a shared health
			 facility shall include in their claims submitted for payment, under the medical
			 assistance program, the registration number assigned to such facility by the
			 State Department of Health.
(e) All
			 third-party insurance benefits covering a recipient, including benefits under
			 title XVIII of the Social Security Act, shall be applied against the cost of
			 medical care and services provided in a shared health facility in accordance
			 with the provisions of section 360.9 of this Title.
(f) The provisions of Part 515 of this Title
			 shall apply to shared health facilities and to any provider, purveyor or
			 operator receiving payments under the medical assistance program, as those
			 terms are defined in 10 NYCRR 83.2.
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 505 - Charges For Professional Health Services › Section 505.23 - Home health services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Policy, scope and definitions.
(1) It is the policy of the department to pay
			 for home health services under the medical assistance (MA) program only when:
(i) the services are medically necessary;
			 and
(ii) the services can maintain
			 the recipient's health and safety in his or her own home, as determined by the
			 certified home health agency in accordance with the regulations of 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 505 - Charges For Professional Health Services › Section 505.24 - Blood, plasma or related products

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The cost of blood, plasma or related
			 products provided by a hospital or by a certified independent health facility
			 are not eligible for reimbursement if the costs of such blood products are
			 included in the financial statement used as the basis for determination of the
			 facility's medical assistance rate.
(b) The cost of blood, plasma or related
			 products when not available without charge or when not provided for as in
			 subdivision (a) of this section, may be eligible for reimbursement if provided
			 on the written order 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 505 - Charges For Professional Health Services › Section 505.25 - Ambulatory care for recipients with mental illness

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Definitions.
(1) For the purposes of the Medical
			 Assistance Program,
ambulatory care for eligible recipients with mental
			 illness
means any arrangement or therapeutic environment for the
			 delivery of medical care, health care, or services meeting the criteria set
			 forth in sections 7.09, 7.15 and
			 31.04 and article 43 of the Mental
			 Hygiene Law, as implemented by appropriate sections of 14 NYCRR Parts 579 and
			 585.
(2) All definitions specified
			 in Parts 579 and 585 of 14 NYCRR apply to this section.
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 505 - Charges For Professional Health Services › Section 505.26 - Chemical dependence outpatient medically supervised withdrawal services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Definitions.
(1) Chemical dependence outpatient medically
			 supervised withdrawal services means services provided under the supervision
			 and direction of a licensed physician, and includes the medical supervision of
			 persons meeting the admission criteria for outpatient medically supervised
			 withdrawal services in section 19.07  of the Mental Hygiene Law, as
			 implemented in Title 14 of the Codes, Rules and Regulations of New York State
			 (14 NYCRR), Part 816.
(2) An
			 occasion of service shall mean a chemical dependence outpatient medically
			 supervised withdrawal service which meets the provisions of 14 NYCRR Part
			 816.
(3) All definitions as
			 specified in 14 NYCRR Part 816 shall apply to this section except, if
			 definitions specifically contained in this section are inconsistent with those
			 contained in 14 NYCRR Part 816, this section shall apply.
(4) OASAS shall mean the Office of Alcoholism
			 and Substance Abuse Services.
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 505 - Charges For Professional Health Services › Section 505.27 - Chemical dependence outpatient services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Definitions.
(1) Chemical dependence outpatient services
			 means services provided under the supervision and direction of a licensed
			 physician, and includes the medical supervision of persons meeting the
			 admission criteria for chemical dependence outpatient services in section 19.07  of the Mental Hygiene Law, as
			 implemented in Title 14 of the Codes, Rules and Regulations of New York State
			 (14 NYCRR), Part 822 or Part 823, as applicable.
(2) An occasion of service shall mean a
			 chemical dependence service which meets the provisions of 14 NYCRR Part 822 or
			 Part 823, as applicable.
(3) All
			 definitions as specified in 14 NYCRR Part 822 or Part 823, as applicable, shall
			 apply to this section except, if definitions specifically contained in this
			 section are inconsistent with those contained in 14 NYCRR Parts 822 and 823,
			 this section shall apply.
(4) OASAS
			 shall mean the Office of Alcoholism and Substance Abuse Services.