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 514 - Provider Verification Of Recipient Eligibility And Orders For Service › Section 514.7 - Clearing of orders for care, services or supplies

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The department may direct a provider who
			 furnishes ordered MA care, services or supplies to obtain authorization to
			 furnish such care, services or supplies through inquiry to EMEVS ("clearing").
			 A provider may be directed to clear prescriptions or fiscal orders is the
			 department determines that the clearing 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, or the clearing provider is furnishing care, services or supplies
			 ordered by a provider required to post, or patterns or volumes of MA
			 transactions by ordering or furnishing providers within a specified geographic
			 area or within a specific provider type warrant the imposition of this
			 additional control to assure the validity of prescriptions or fiscal
			 orders.
(b) When a provider who
			 furnishes ordered care, services or supplies ordered by a provider required to
			 post orders for care, services or supplies clears a prescription or fiscal
			 order, EMEVS will respond with a message indicating whether the payment of
			 claims for care, services or supplies will be made.
(c) If a provider who is directed by the
			 department to clear prescriptions or fiscal orders fails to clear a
			 prescription or fiscal order which is required to be posted to EMEVS and which
			 either has not been posted or has been posted and already filled, the
			 department will deny payment for the ordered care, services or supplies. If the
			 department finds a significant number of unjustified failures by the provider
			 to clear orders, 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 515 - Provider Sanctions › Section 515.1 - Scope and definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Scope.
			 This Part sets forth the requirements and procedures for:
(1) sanctioning persons under the medical
			 assistance program;
(2) recovering
			 overpayments resulting from unacceptable practices;
(3) obtaining restitution;
(4) administrative appeals of sanctions and
			 overpayments; and
(5) reinstatement
			 into 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 515 - Provider Sanctions › Section 515.2 - Unacceptable practices under the medical assistance program

Current through Register Vol. 46, No. 28, July 10, 2024
(a) General. An
			 unacceptable practice is conduct by a person which is contrary to:
(1) the official rules and regulations of the
			 department;
(2) the published fees,
			 rates, claiming instructions or procedures of the department;
(3) the official rules and regulations of the
			 Departments of Health, Education and Mental Hygiene, including the latter
			 department's offices and divisions, relating to standards for medical care and
			 services under the program; or
(4)
			 the regulations of the Federal Department of Health and Human Services
			 promulgated under title XIX of the Federal Social Security Act.
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 515 - Provider Sanctions › Section 515.3 - Authority to sanction

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Upon a
			 determination that a person has engaged in an unacceptable practice, the
			 department may impose one or more of the following sanctions:
(1) exclusion from the program for a
			 reasonable time;
(2) censure;
			 or
(3) conditional or limited
			 participation, such as requiring preaudit or prior authorization of claims for
			 all medical care, services or supplies, prior authorization of specific medical
			 care, services or supplies, or other similar conditions or
			 limitations.
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 515 - Provider Sanctions › Section 515.4 - Guidelines for sanctions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
			 sanction may be imposed at the discretion of the department upon a
			 determination that a person has engaged in one or more unacceptable
			 practices.
(b) In determining the
			 sanction to be imposed, the following factors will be considered:
(1) the number and nature of the program
			 violations or other related offenses;
(2) the nature and extent of any adverse
			 impact the violations have had on recipients;
(3) the amount of damages to the
			 program;
(4) mitigating
			 circumstances;
(5) other facts
			 related to the nature and seriousness of the violations; and
(6) the previous record of the person under
			 the Medicare, Medicaid and social services programs.
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 515 - Provider Sanctions › Section 515.5 - Sanctions; effect

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No payments
			 will be made to or on behalf of any person for the medical care, services or
			 supplies furnished by or under the supervision of the person during a period of
			 exclusion or in violation of any condition of participation in the program. In
			 the case of a hospital, nursing home or home health care provider, the
			 department may continue payments for up to 30 days after the date of exclusion
			 for clients admitted prior to the exclusion or whose plan of care was
			 implemented prior to the exclusion.
(b) No payment will be made for medical care,
			 services or supplies ordered or prescribed by any person while that person is
			 excluded, nor for any medical care, services or supplies ordered or prescribed
			 in violation of any condition of participation in the program. The department
			 may pay the first claim(s) submitted by or on behalf of a dispensing provider
			 for care, services or supplies ordered or prescribed by an excluded person
			 after the date of exclusion and notify the dispensing provider of the
			 exclusion. The department may not pay for any care, services or supplies
			 ordered or prescribed by an excluded person more than 20 days after the date of
			 a notice of an exclusion to a dispensing provider.
(c) A person who is excluded from the program
			 cannot be involved in any activity relating to furnishing medical care,
			 services or supplies to recipients of medical assistance for which claims are
			 submitted to the program, or relating to claiming or receiving payment for
			 medical care, services or supplies during the period.
(d) Providers reimbursed on a cost-related
			 basis may not claim as allowable costs any amounts paid or credited to any
			 person who is excluded from the program or who is in violation of any condition
			 of participation in the program.
(e) Providers reimbursed on a
			 fee-for-services basis may not submit any claim and cannot be reimbursed for
			 any medical care, services or supplies furnished by any person who is excluded
			 from the program or which are furnished in violation of any condition of
			 participation in the 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 515 - Provider Sanctions › Section 515.6 - Notification

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Notice of
			 proposed agency action.
(1) If the department
			 proposes to sanction a person or to require restitution or repayment of
			 overpayments under this Part, it must first send the person a written notice of
			 proposed agency action stating the reasons for the proposed action, the legal
			 authority for the action, the nature and amount of any overpayment determined
			 to have been made as a result of the unacceptable practices and the notice also
			 must advise the person of the opportunity to submit documentation or written
			 arguments objecting to the proposed action within 30 days of receipt of the
			 notice. The notice must state that the failure to object within the time
			 provided may result in the adoption of the proposed action as the final agency
			 action and that, pursuant to section
			 519.18  of this
			 Title, the issues to be addressed at an administrative hearing will be limited
			 to those matters contained in any objection to the proposed action. The notice
			 must be sent to the person's designated correspondence address, address
			 designated for receipt of payments or last known address.
(2) Any documentation or written arguments
			 submitted by a person objecting to the proposed agency action must be mailed
			 within 30 days of receipt of the notice of proposed agency action which will be
			 presumed in the absence of evidence to the contrary to be five days after the
			 date on the notice of proposed agency action. The objections must include a
			 written statement detailing the specific items in the notice of proposed agency
			 action to which the person objects.
(3) For good cause shown, the department may
			 extend the 30-day period.
(4) After
			 review of the documentation or arguments submitted against the proposed agency
			 action, if any, the department may issue a notice of agency action.
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 515 - Provider Sanctions › Section 515.7 - Immediate sanctions

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Notwithstanding any provision of this Title to the contrary, the department,
			 upon notice to the person, may take immediate action under this
			 section.
(b) Upon receiving notice
			 of an indictment which charges a person with committing an act which would be a
			 felony under the laws of New York and which relates to or results from:
(1) the furnishing or billing for medical
			 care, services or supplies; or
(2)
			 participation in the performance of management or administrative services
			 relating to furnishing medical care, services or supplies, the department may
			 immediately exclude the person and any affiliates, and may continue the
			 exclusion for 90 days following receipt of notice of the disposition of the
			 indictment.
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 515 - Provider Sanctions › Section 515.8 - Mandatory exclusions

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Notwithstanding any provision of this Title to the contrary, the following
			 persons are immediately excluded from participation in the medical assistance
			 program:
(1) a person who is excluded or
			 terminated from participation in the Federal Medicare program;
(2) a health maintenance organization (HMO)
			 furnishing services under a waiver granted pursuant to Federal law when:
(i) any affiliate of such HMO or person with
			 whom the HMO has a significant business transaction is convicted of a criminal
			 offense under section 1128 of the Federal Social Security Act;
(ii) any affiliate of such HMO or person with
			 whom the HMO has a significant business transaction is assessed civil money
			 penalties under section 1128A of the Federal Social Security Act; or
(iii) such HMO has been excluded from the
			 Federal Medicare program or any states' health care 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 515 - Provider Sanctions › Section 515.9 - Overpayments

Current through Register Vol. 46, No. 28, July 10, 2024
Any overpayments identified pursuant to any investigation
			   under this Part may be recovered in conjunction with a proceeding under this
			   Part and in accordance with Parts 518 and 520 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 515 - Provider Sanctions › Section 515.10 - Reinstatement

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A person
			 sanctioned under this Part may request reinstatement, or removal of any
			 condition or limitation on participation in the medical assistance program, at
			 any time after the date or time period specified in the notice of agency
			 action, or upon the occurrence of an event specified in the notice.
(b) A request for reinstatement or for
			 removal of any condition or limitation on participation in the program is made
			 as an application for enrollment under Part 504 of this Title and must be
			 denominated as a request for reinstatement to distinguish it from an original
			 application.
(c) The request for
			 reinstatement must be sent to the provider enrollment unit of the
			 department.
(d) The request must:
(1) include a complete ownership and control
			 disclosure statement;
(2) state
			 whether the party has been convicted of other offenses related to participation
			 in the Medicare, Medicaid or social services programs which were not considered
			 during the development of the sanction; and
(3) state whether any State or local
			 licensing authorities have taken any adverse action against the party for
			 offenses related to participation in the Medicare, Medicaid or social services
			 programs which were not considered during the development of the
			 sanction.
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 515 - Provider Sanctions › Section 515.12 to 515.13

Current through Register Vol. 46, No. 28, July 10, 2024
New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 515 - Provider Sanctions › Section 515.15 to 515.18

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 516 - Monetary Penalties › Section 516.2 - Notice

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Notice of
			 proposed agency action.
(1) When OMIG
			 proposes to impose a monetary penalty under this Part, OMIG must first send the
			 person a written notice of proposed agency action. Such notice must be mailed
			 to the person's designated payment address, designated correspondence address,
			 or last known address.
(2) The
			 notice of proposed agency action must contain:
(i) the alleged violation(s);
(ii) facts which support the conclusion that
			 a violation has occurred;
(iii) the
			 amount of the proposed monetary penalty;
(iv) the legal authority for the
			 penalty;
(v) the opportunity for
			 the person to submit documentation or written arguments objecting to the
			 proposed action within 30 calendar days of receipt of the notice of proposed
			 agency action. The objections must be in writing and include a written
			 statement detailing the specific items in the notice of proposed agency action
			 to which the person objects; and
(vi) a statement that the failure to object
			 within the time provided may result in the adoption of the proposed penalties
			 as the final penalties and that, pursuant to section
			 519.18  of this
			 Title, the issues to be addressed at an administrative hearing will be limited
			 to those matters contained in any objection to the proposed action.
(3) Any documentation or written
			 arguments submitted by the person objecting to the notice of proposed agency
			 action must be mailed to OMIG, at the address specified in the notice of
			 proposed agency action, within 30 calendar days of receipt of the notice of
			 proposed agency action which will be presumed, in the absence of evidence to
			 the contrary, to be five calendar days after the date on the notice of proposed
			 agency action.
(4) For good cause
			 shown, OMIG may, in its discretion, extend the 30-calendar day period to
			 respond to the notice of proposed agency action.
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 516 - Monetary Penalties › Section 516.3 - Effect and enforcement of the penalty

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
(1) The
			 imposition of a penalty under this Part does not preclude the recovery of an
			 overpayment or the imposition of any other penalty authorized by Federal or
			 State law or regulation.
(2)
			 Notwithstanding the imposition of any penalty under this Part, the department
			 may also sanction a person pursuant to 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 517 - Provider Audits › Section 517.1 - Scope

Current through Register Vol. 46, No. 28, July 10, 2024
(a) This Part
			 applies to fiscal audits and reviews of a provider's claims, books, records,
			 reports or other available documentation.
(b) Audits and reviews conducted pursuant to
			 this Part do not preclude the department or any other authorized governmental
			 body or agency from taking any other action with respect to the provider,
			 including obtaining overpayments or restitution pursuant to a finding of
			 unacceptable practices, auditing or reviewing of other payments or claims for
			 payment for the same or similar periods, or taking any other action authorized
			 by law.
New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 517 - Provider Audits › Section 517.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The terms defined in Part 515 of this Title have the same
			   meanings in this Part and, in addition, as used in this Part, the following
			   terms shall have the following meanings:
(a) Facility shall mean:
(1) any medical facility, hospital, nursing
			 home, residential care facility, home health agency, health maintenance
			 organization and diagnostic and treatment center as defined in the Public
			 Health Law; or
(2) any program or
			 facility for which the Office of Mental Retardation and Developmental
			 Disabilities establishes fees or rates of payment under the medical assistance
			 program and which is not operated by such Office.
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 517 - Provider Audits › Section 517.3 - Audit and record retention

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Cost-based provider.
(1) All fiscal and
			 statistical records and reports of providers which are used for the purpose of
			 establishing rates of payment made in accordance with the medical assistance
			 program and all underlying books, records, documentation and reports which
			 formed the basis for such fiscal and statistical records and reports are
			 subject to audit. All underlying books, records and documentation which formed
			 the basis for the fiscal and statistical reports filed by a provider with any
			 State agency responsible for the establishment of rates of payment or fees must
			 be kept and maintained by the provider for a period of not less than six years
			 from the date of filing of such reports, or the date upon which the fiscal and
			 statistical records were required to be filed, or two years from the end of the
			 last calendar year during any part of which a provider's rate or fee was based
			 on the fiscal or statistical reports, whichever is later. In this respect, any
			 rate of payment certified or established by the commissioner of the Department
			 of Health or other official or agency responsible for establishing such rates
			 will be construed to represent a provisional rate until an audit is performed
			 and completed, or the period within which to conduct an audit has expired
			 without such audit having been begun or notice of such audit having been
			 issued, at which time such rate or adjusted rate will be construed to represent
			 the final rate as to those items audited.
(2) All required fiscal and statistical
			 reports are subject to audit for a period of six years from the date of their
			 filing or from the date when such reports were required to be filed, whichever
			 is later. This limitation does not apply to situations in which fraud may be
			 involved or where the provider or an agent thereof prevents or obstructs the
			 commissioner from performing an audit pursuant to this Part. Where reports and
			 documentation have been submitted pursuant to a rate appeal of a provisional
			 rate, such reports and documentation will likewise be subject to audit for a
			 period of six years from the submission of material in support of such appeal
			 or two years following certification of any revised rate resulting from such
			 appeal, whichever is later.
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 517 - Provider Audits › Section 517.5 - Draft audit report

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If, after
			 affording the provider the opportunity for a closing conference upon completion
			 of an on-site field audit and after consideration of any additional
			 documentation and information presented in connection therewith, or after a
			 review of a provider's claims and payments on in-house post-payment review, the
			 department believes that overpayments have been made to the provider, a draft
			 audit report may be issued identifying the items which are being disallowed and
			 advising the provider of the basis for the proposed action and the legal
			 authority therefor. When feasible, the draft report will also specify the
			 amount of the overpayment.
(b) The
			 draft audit report must contain a clear statement of the action to be taken,
			 must afford the provider the opportunity to object to the proposed action
			 within 30 days of receipt of this notice, must advise the provider that failure
			 to object within the time provided may result in the adoption of the proposed
			 action as the final agency action and must advise the provider that, pursuant
			 to section
			 519.18  of this
			 Title, the issues to be addressed at an administrative hearing will be limited
			 to those matters contained in any objection to the proposed action.
(c) The report must be mailed to the
			 provider's designated payment address or correspondence address or last known
			 address and must be accompanied by a document identifying the person to whom
			 objections to the report should be mailed. The provider's objections to the
			 draft audit report must be mailed by the provider to that person within 30 days
			 of receipt of the report which will be presumed in the absence of evidence to
			 the contrary to be five days after the date on the draft report. Any objection
			 must include a statement detailing the specific items of the draft report to
			 which the provider objects and provide any additional material or documentation
			 which the provider wishes to be considered in support of the
			 objections.
New York Codes, Rules and Regulations › Title 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 517 - Provider Audits › Section 517.6 - Final audit report

Current through Register Vol. 46, No. 28, July 10, 2024
(a) After
			 receipt of the provider's objections to the draft audit report, or at any time
			 after the expiration of 40 days after mailing of the draft audit report without
			 objections having been received, a final report may be issued. In preparing the
			 final audit report, the department must consider the objections, any supporting
			 documents and materials submitted therewith, the draft audit report, and any
			 additional material which may become available.
(b) The final audit report and/or the cover
			 letter accompanying it must clearly advise the provider:
(1) of the nature and amount of the audit
			 findings, the basis for the action and the legal authority therefor;
(2) of the action which will be
			 taken;
(3) of the effective date of
			 the intended action which will be not less than 20 days from the date of the
			 final audit report;
(4) of the
			 right to appeal the audit findings set forth in the final audit report and of
			 the requirements and procedures for requesting an administrative
			 hearing;
(5) that the request may
			 not address issues regarding the methodology used to determine the rate or any
			 issue that was raised or could have been raised at a proceeding to appeal a
			 rate determination but shall be limited to those issues relating to
			 determinations contained in the final audit report.
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 517 - Provider Audits › Section 517.7 to 517.13

Current through Register Vol. 46, No. 28, July 10, 2024
New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 517 - Provider Audits › Section 517.14 - Rate adjustments after audit

Current through Register Vol. 46, No. 28, July 10, 2024
Audit adjustments which result in rate revisions must be
			   applied to all rate periods which are affected by the audited costs. Any
			   resulting adjustment to the reimbursement of a provider may be satisfied
			   pursuant to Part 518 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 517 - Provider Audits › Section 517.15 to 517.16

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 517 - Provider Audits › Section 517.17 - Transferred audits

Current through Register Vol. 46, No. 28, July 10, 2024
Providers which requested bureau reviews in accordance
			   with the provisions of 10 NYCRR Part 86 and which did not receive final
			   determinations based thereupon are entitled to a final audit report in
			   accordance with the provisions of section
			   517.6  of this
			   Part and to a hearing in accordance with the provisions of Part 519 of this
			   Title. Providers which have requested hearings in accordance with 10 NYCRR Part
			   86 or former Part 518 of this Title are entitled to a hearing in accordance
			   with Part 519 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 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.1 - Scope

Current through Register Vol. 46, No. 28, July 10, 2024
(a) This Part sets
			 forth the procedures for the recovery of overpayments determined to be due the
			 department under the medical assistance program and for withholding payments
			 otherwise due a provider.
(b) When
			 the department has determined that any person has submitted or caused to be
			 submitted claims for medical care, services or supplies for which payment
			 should not have been made, it may require repayment of the amount determined to
			 have been overpaid.
(c) An
			 overpayment includes any amount not authorized to be paid under the medical
			 assistance program, whether paid as the result of inaccurate or improper cost
			 reporting, improper claiming, unacceptable practices, fraud, abuse or
			 mistake.
(d) Recovery of
			 overpayments may be made in connection with an audit, review or investigation
			 under Part 515 or 517 of this Title, or in connection with other reviews or
			 audits by authorized local, State or Federal agencies available to the
			 department.
New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The definitions in Parts 515 and 517 of this Title apply
			   to this Part.
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 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.3 - Liability for overpayments

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
			 department may require repayment from the person submitting an incorrect or
			 improper claim, or the person causing such claim to be submitted, or the person
			 receiving payment for the claim.
(b) The department may require repayment for
			 inappropriate, improper, unnecessary or excessive care, services or supplies
			 from the person furnishing them, or the person under whose supervision they
			 were furnished, or the person causing them to be furnished. In this respect,
			 the department may recover the amount paid for such care, services or supplies
			 from the person ordering or prescribing them even though payment was made to
			 another person. Medical care, services or supplies ordered or prescribed will
			 be considered excessive or not medically necessary unless the medical basis and
			 specific need for them are fully and properly documented in the client's
			 medical record.
(c) Persons
			 furnishing, or supervising the furnishing of, medical care, services or
			 supplies are jointly and severly liable for any overpayments resulting from the
			 furnishing of the care, services or supplies. The amount of repayment which may
			 be recovered from any person is the amount paid for furnishing the medical
			 care, services or supplies, plus the amount paid to any other person as a
			 result of his/her ordering or prescribing medical care, services or supplies,
			 less any amount actually recovered from any other person which relates to the
			 care, services or supplies for which repayment is sought.
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 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.4 - Interest

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Interest may be
			 collected upon any overpayments determined to have been made and will accrue at
			 the rate and in the manner set forth in this section.
(b) Prior to the issuance of a notice of
			 determination, interest will accrue at the current rate from the date of the
			 overpayment.
(c) After the issuance
			 of a notice of determination, interest will accrue at the current rate, plus
			 two percentage points, or the maximum legal rate, whichever is lower.
(d) The current rate for purposes of this
			 section is the annual rate of interest as fixed by the department, in
			 consultation with the State Comptroller or superintendent of the Banking
			 Department, after taking into consideration private consumer rates of interest
			 prevailing on the date that the department became entitled to recovery of the
			 overpayment. The rate may be revised quarterly by the department.
(e) Interest may be waived in whole or in
			 part when the department determines the imposition of interest would effect an
			 unjust result, would unduly burden the provider or would substantially delay
			 the prompt and efficient resolution of an outstanding audit or investigation.
			 No interest will be imposed upon any inpatient facility established under
			 article 28 of the Public Health Law as a result of an audit of its costs for
			 any period prior to the issuance of a notice of determination, nor for a period
			 of at least 90 days after issuance of such notice.
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 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.5 - Recovery of overpayments; procedure

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Except as provided in subdivision (b) of
			 this section, when a determination is made that an overpayment has been made,
			 any person from whom recovery is sought is entitled to a notice of the
			 overpayment and an opportunity to be heard in accordance with the procedures
			 established under Part 519 of this Title. The procedures under Part 515 or 517
			 of this Title govern the process for determining the nature and amount of the
			 overpayment and making any administrative appeals.
(b) The procedures set forth in subdivision
			 (a) of this section do not apply where the department or its fiscal agent
			 adjusts or denies a claim prior to payment or withholds payment pursuant to a
			 notice of withholding.
(c) The
			 department reserves the right to initiate or participate in civil proceedings,
			 including actions at law or in equity to recover any overpayment where the
			 action or proceeding would be more efficient or effective or in the best
			 interests of the 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 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.6 - Recoupment of overpayments

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Overpayments may be recovered by withholding all or part of a provider's and an
			 affiliate's payments otherwise payable, at the option of the
			 department.
(b) Any money due to
			 the provider from the department may be used as an offset against any
			 overpayments.
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 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.7 - Withholding of payments

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Basis
			 for withholding.
(1) The department may
			 withhold payments under the program, in whole or in part, when it has
			 determined that a provider has abused the program or has committed an
			 unacceptable practice. The department's determination that a provider has
			 abused the program, or has committed an unacceptable practice may consist of
			 preliminary findings by the department's audit or utilization review staff of
			 unacceptable practices or significant overpayments, information from a State
			 professional licensing or certifying agency of an ongoing investigation of a
			 provider involving fraud, abuse, professional misconduct or unprofessional
			 conduct, or information from a State investigating or prosecutorial agency or
			 other law enforcement organization of an ongoing investigation of a provider
			 for fraud or criminal conduct involving the program. The department may
			 withhold payment of current and future claims to the provider and any
			 affiliate.
(2) The department must
			 withhold payments under the program, in whole or in part, when it has
			 determined or has been notified that a provider is the subject of a pending
			 investigation of a credible allegation of fraud unless the department finds
			 good cause not to withhold payments in accordance with
			 42 C.F.R.
			 455.23. A credible allegation of fraud is an
			 allegation that has indicia of reliability and has been verified by the
			 department, or the Medicaid fraud control unit, or another State agency, or law
			 enforcement organization.
(i) Whenever the
			 department initiates a withholding, in whole or in part, in relation to a
			 pending investigation of a credible allegation of fraud, the department must
			 make a fraud referral to the Medicaid fraud control unit. If the Medicaid fraud
			 control unit does not accept the referral, then the department may refer the
			 matter to another law enforcement organization.
(ii) The fraud referral made under this
			 paragraph must be in writing and provided to the Medicaid fraud control unit or
			 other law enforcement organization not later than the next business day after
			 the withhold is enacted.
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 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.8 - Recovery of overpayments pending a hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The department may, upon notice to the
			 provider and not sooner than 20 days after issuance of the final audit report
			 or notice of agency action, commence recoupment of overpayments.
(b) If a request for hearing has been timely
			 made and the department's office of administrative hearings is unable to
			 schedule the hearing so that it is commenced within 90 days of receipt of such
			 request or if the department is unable to proceed within 90 days of receipt of
			 such request, any recovery begun under this section will be stayed pending the
			 commencement of the hearing. If a hearing has been scheduled to commence within
			 90 days of receipt of a hearing request, any delays or adjournments of the
			 commencement of the hearing occasioned by or attributable to the provider, his
			 or her attorney or authorized representative will not forestall the
			 commencement or continuation of recoupment. However, any delays or adjournments
			 occasioned by or attributable to the department will forestall the commencement
			 or continuation of recoupment.
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 518 - Recovery And Withholding Of Payments Or Overpayments › Section 518.9 - Incorporation by reference

Current through Register Vol. 46, No. 28, July 10, 2024
The provisions of the Code of Federal Regulations which
			   have been incorporated by reference in this Part have been filed in the Office
			   of the Secretary of State of the State of New York, the publication so filed
			   being the booklet entitled: Code of Federal Regulations, title 42, parts
			   455.23, revised as of October 1, 2011, published by the Office of the Federal
			   Register, National Archives and Records Administration, as a special edition of
			   the Federal Register. The regulations incorporated by reference may be examined
			   at the Office of the Department of State, 99 Washington Avenue, Albany, NY
			   12231 at the law libraries of the New York State Supreme Court and the New York
			   State, and at the Office of the Medicaid Inspector General, Office of Counsel,
			   800 N. Pearl Street, Albany, NY 12204. They may also be purchased from the
			   Superintendent of Documents, Government Printing Office, Washington, DC 20402.
			   Copies of the Code of Federal Regulations are also available at many public
			   libraries and bar association libraries.
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 519 - Provider Hearings › Section 519.1 - Scope

Current through Register Vol. 46, No. 28, July 10, 2024
(a) These
			 regulations govern the hearing process for providers of medical assistance and
			 other persons sanctioned by the department or from whom the department requests
			 repayment of overpayments or restitution.
(b) The commissioner of the State Department
			 of Social Services will consider all appeals on the basis of the participation
			 and payment requirements of 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 519 - Provider Hearings › Section 519.2 - General

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Notice. These
			 regulations set forth the information which must be provided whenever the
			 department imposes a sanction or requires repayment of overpayments or payment
			 of restitution.
(b) Timing. These
			 regulations set forth the time periods within which to request a hearing and
			 the time periods within which hearings are to be scheduled and decisions
			 issued.
(c) Procedures. These
			 regulations set forth what must be done to have a determination reviewed,
			 including how to request another hearing date and how to obtain an interpreter
			 if the person does not speak English or is deaf. These regulations also explain
			 who may come to a hearing.
(d)
			 Information. These regulations set forth what information and documents are to
			 be provided to persons who have requested a hearing.
(e) Decision. These regulations set forth
			 what to do if the department refuses to comply with the hearing
			 decision.
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 519 - Provider Hearings › Section 519.3 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The definitions set forth in Parts 515 and 517 of this
			   Title apply to this Part. In addition, the following terms have the following
			   meanings:
(a) Appellant is any person
			 who requests a hearing or his/her authorized representative.
(b) Final determination is a final audit
			 report or notice of agency action sanctioning a person, or requiring the
			 repayment of overpayments or restitution.
(c) Hearing is the procedure by which a
			 person may appeal from determinations of the department sanctioning a person or
			 requiring the repayment of overpayments or payment of restitution.
(d) Hearing officer is a person who is
			 employed by the department to conduct administrative hearings.
(e) Parties are the appellant and the
			 department.
(f) Mass change is a
			 change initiated by the department or the Legislature which affects all or a
			 significant portion of all providers.
(g) Witness is a person who presents
			 testimony and/or documentary evidence at a hearing, other than the provider,
			 his/her representative or the representative of the department.
New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 519 - Provider Hearings › Section 519.4 - Right to a hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
			 person is entitled to a hearing to have the department's final determination
			 reviewed if the department:
(1) imposes a
			 sanction; or
(2) requires the
			 repayment of an overpayment or restitution; or
(3) seeks to impose a penalty pursuant to
			 Part 516 of this Title.