New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter F - Finance; Claims for Reimbursement by Social Services Districts › Article 1 - Reimbursement and Claims › Part 601 - Procedures Of Reimbursement Claiming › Section 601.4 - Claim adjudication

Current through Register Vol. 46, No. 28, July 10, 2024
The department will be responsible for examining claims
			   for reimbursement submitted by social services districts. Initial
			   determinations objecting to the allowability of a claim for reimbursement will
			   be made in a timely manner not to exceed 90 days from the time of receipt by
			   the department, unless the department notifies a district that a specified
			   amount of additional time, not to exceed an additional 90 days, is necessary to
			   complete examination of the claim. Any portion of a claim to which there is no
			   initial determination objecting to allowability will be processed for
			   submission for acceptance by a reimbursement authority. Processing will be
			   commenced in a timely manner not to exceed 90 days from the time of receipt of
			   the claim or from the date of an initial determination of allowability. A
			   determination by the department concerning the allowability of a claim for
			   reimbursement submitted by a social services district is final and is not
			   subject to administrative review.
(a)
			 Acceptance or payment by the department of any portion of any claim for such
			 reimbursement does not preclude the department from subsequently examining any
			 portion of such claim and determining that such claim was not subject to
			 reimbursement or should have been reimbursed at a different rate.
(b) Acceptance by the district of
			 reimbursement from the department related to specific reimbursable costs
			 claimed by the district precludes the district from subsequently submitting any
			 additional claims for reimbursement for such costs without the consent of the
			 department.
(c) Acceptance by a
			 social services district of a determination by the department with respect to
			 the allowability of costs or other items purported to be subject to
			 reimbursement on any portion of any claim precludes the district from
			 submitting any additional claims for reimbursement relating to such costs or
			 items without the consent of the department.
(d) Any portion of any costs or other items
			 purported to be subject to reimbursement which are determined to be
			 unacceptable by the department may not be resubmitted for reimbursement or
			 otherwise adjusted without the explicit consent of the department.
(e) The department may request the district
			 to submit, or at the department's option prepare on behalf of the district, a
			 statement of adjustments to any portion of any claim submitted by a district.
			 Any adjustments made by the department to payments or claims for the district
			 constitutes notification of the adjustment when the district receives a copy of
			 the adjustment or has been notified that the adjustment has been
			 made.
(f) Any disallowances,
			 recoupments or adjustments resulting from the action or determination of a
			 Federal or other reimbursement authority must be reflected in adjustments to
			 claims as directed by the department. A copy of any adjustments made by the
			 department constitutes notification to the district of the adjustments when the
			 district receives a copy of the adjustment or is notified that the adjustment
			 has been made. If the determination of the Federal or other reimbursement
			 authority is not final or binding, or if the department has appealed or
			 judicially challenged such determination and the district is so notified, the
			 determination of the department with respect to the district shall not be final
			 and binding until the determination is final and binding upon the department
			 and the district is so notified.
(g) Any adjustments resulting from a
			 post-claim review or audit must be reflected in adjustments to claims as
			 directed by the department. A copy of any adjustments made by the department
			 constitutes notification to the district of the adjustment when the district
			 receives a copy of the adjustment or has been notified that the adjustment has
			 been made.
(h) Any other
			 reductions, recoupments or adjustments must be reflected in adjustments to
			 claims as directed by the department. Such reductions, recoupments or
			 adjustments when made by the department are final and binding when the district
			 is notified that the reduction, recoupment or adjustment has been or will be
			 made.