New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 5 - Procedures and Forms › Part 540 - Authorization Of Medical Care › Section 540.5 - Authorization by public welfare officials

Current through Register Vol. 46, No. 28, July 10, 2024
(a) General. Whenever prior authorization for
			 any item of medical assistance is required, the public welfare official shall
			 give notification to the vendor in accordance with the requirements of this
			 section.
(1) The public welfare official
			 shall either accept liability for the cost of the medical care requested by
			 issuing an authorization to the vendor containing the minimum essentials listed
			 below, or he shall deny responsibility by notifying the vendor in writing of
			 his rejection of the notification. It is desirable that the acceptance of the
			 notification be issued to the vendor in writing, but, if the public welfare
			 official prefers, he may arrange wth the vendor that acceptance of liability
			 may be assumed unless a notice of rejection is received by the vendor. Whether
			 or not the acceptance of liability is issued to the vendor in writing, a
			 written authorization containing the minimum essentials listed below shall be
			 forwarded by the authorizing official to the disbursing unit of the public
			 welfare agency, the information contained in such written authorization
			 becoming the basis for payment by the disbursing unit of the agency to the
			 medical vendor. Such authorizations shall be subject to the same limitations
			 and control as are specified in section
			 540.6 
			 of this Part.
(2) Decision as to
			 acceptance or rejection of notification and request for authorization shall be
			 made as promptly as possible by the public welfare official.
(3) If the notification and request for
			 authorization is accepted by the public welfare official, the authorization to
			 the vendor (or vendors) shall contain, as a minimum, the following information:
(i) case identification and patient
			 designation;
(ii) effective date of
			 services for which public welfare official assumes liability;
(iii) expiration date of
			 authorization;
(iv) volume of
			 service authorized;
(v) type,
			 character or nature of services authorized;
(vi) vendor authorized to provide such
			 services;
(vii) source of payment
			 (if other than agency);
(viii)
			 signature of authorizing official and date of issuance;
(ix) signature of supervisor of medical
			 services, when required by nature of service.
(4) The agency shall utilize a form of
			 authorization containing such minimal information, as illustrated in section B
			 of illustrative form M-1, contained in the instructions of the
			 department.
(5)
(i) After May 14, 1976, the local social
			 services official shall authorize medical assistance payments only after
			 obtaining documentation of the following actions for persons admitted on or
			 after May 14, 1976 to skilled nursing facilities holding title XVIII provider
			 agreements:
(a) that the Commissioner of
			 Health or his designee has approved admission and continued stay in a skilled
			 nursing facility; and
(b) that the
			 admitting facility has prepared written justification of the decision not to
			 make application to Medicare because of the patient's apparent technical
			 ineligibility; or
(c) that
			 application has been made for Medicare benefits and rejected as being
			 ineligible; and
(d) that
			 reconsideration of the Medicare rejection has been initiated or, when the
			 skilled nursing facility agrees with Medicare's reasons for rejecting, a
			 written justification of their agreement has been submitted to the local
			 medical director.
(ii)
			 Skilled nursing facilities shall not be required to initiate requests for
			 reconsideration in cases where they agree with Medicare's rejection. The
			 Commissioner of Health or his designee, however, shall review the skilled
			 nursing facility's justifications for agreeing with Medicare. In those
			 instances in which the Commissioner of Health or his designee disagrees with
			 the Medicare rejection, the social services official shall require the skilled
			 nursing facility to initiate a reconsideration of Medicare's
			 decision.
(iii) Should the Medicare
			 reconsideration process fail to reverse the initial rejection, the local social
			 services district shall assume responsibility for insuring that a Medicare
			 appeal is initiated in each appropriate instance.
(iv) Appeals, when deemed to be appropriate,
			 must be initiated within 14 calendar days of the date of the fiscal
			 intermediary's notification that the reconsideration process had failed to
			 reverse the original decision.