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 519 - Provider Hearings › Section 519.5 - Notice

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The department
			 must issue a written notice of a final determination to the person if it
			 intends to sanction him/her, or require repayment of an overpayment or
			 restitution.
(b) The notice must be
			 mailed to the person's designated payment or correspondence address or last
			 known address.
(c) The notice must
			 clearly state the determination made, the basis and specific reasons for the
			 determination, the effect of any action to be taken, the amount of any
			 overpayment or penalty, and the effective date of the action. The notice must
			 also include information concerning the right to a hearing.
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 519.6 - Information concerning the right to a hearing

Current through Register Vol. 46, No. 28, July 10, 2024
Every person has the right to receive certain information
			   in writing when the department issues a final determination. Each person
			   sanctioned, or from whom the department requests payment, has the right to a
			   notice which advises him/her:
(a) of
			 the hearing right;
(b) how to
			 obtain a hearing;
(c) of the right
			 to be represented at the hearing, or to represent himself/herself;
			 and
(d) of the types of information
			 which may be submitted at the hearing.
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 519.7 - Request for a hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Any
			 clear, written communication to the department by or on behalf of a person
			 requesting review of a department's final determination is a request for a
			 hearing if made within 60 days of the date of the department's written
			 determination.
(b) A hearing may be
			 requested by writing:
New York State Department of Social Services
Bureau of Special Hearings
40 N. Pearl Street
Albany, NY 12243
New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 519 - Provider Hearings › Section 519.8 - Hearing rights

Current through Register Vol. 46, No. 28, July 10, 2024
By requesting a hearing, a person becomes the appellant
			   and has the right to:
(a) request the
			 department to reschedule the hearing (adjournment);
(b) be represented by an attorney, or other
			 representative, or to represent himself/herself;
(c) have an interpreter, at no charge, if the
			 appellant does not speak English or is deaf and cannot afford one (the
			 appellant must advise the department prior to the hearing if an interpreter
			 will be needed);
(d) produce
			 witnesses and present written and/or oral evidence to explain why the action
			 taken as wrong; and
(e)
			 cross-examine witnesses 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 519.9 - Authorization of representative

Current through Register Vol. 46, No. 28, July 10, 2024
An individual or organization, other than an attorney,
			   representing an appellant must have a signed, written authorization from the
			   appellant, unless it is impracticable for him/her to execute
			   one.
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 519.10 - Notice of hearing

Current through Register Vol. 46, No. 28, July 10, 2024
At least 15 calendar days prior to the date of the
			   hearing, written notice must be sent to the parties and their representatives.
			   The notice must inform them of:
(a)
			 the date, time and place of the hearing and the parties' right to request an
			 adjournment or change of venue;
(b)
			 the manner and means by which adjournments or changes of venue may be requested
			 and granted;
(c) the issues which
			 are to be the subject of the hearing;
(d) the manner in which the hearing will be
			 conducted; and
(e) the right of
			 each party to be represented or to represent himself/herself, to testify, to
			 produce witnesses, to present documentary evidence and to examine opposing
			 witnesses.
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 519.11 - Scheduling and adjourning the hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The hearing will be held at a time and in
			 an office of the department which are convenient to the appellant, as far as
			 practicable.
(b) Requests for
			 adjournments of any scheduled hearing must be in writing and made as far in
			 advance of the scheduled hearing date as practicable, upon notice to the
			 opposing party. Adjournments will not be routinely given as hearing dates are
			 considered dates certain. However, upon written request, an appellant or the
			 department may have the hearing rescheduled to another date upon a showing of
			 good cause. Claims of court engagement will require submission of a detailed
			 affidavit of actual engagement and claims of illness will require medical
			 documentation. Adjournments in contemplation of settlement will require the
			 consent of both parties.
(c) During
			 the course of a hearing, the hearing officer may adjourn the hearing when
			 fundamental fairness would best be served by adjourning the hearing.
(d) Written requests to adjourn a hearing
			 made prior to the date of the hearing must be made to the Bureau of Special
			 Hearings in accordance with the instructions in the notice of hearing. Requests
			 for adjournments made on the day of the hearing must be in writing to the
			 hearing officer.
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 519.12 - Withdrawal or abandonment of a request for hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A request for a hearing is abandoned if
			 the hearing has not been rescheduled and the appellant does not appear at the
			 hearing on the scheduled date.
(b)
			 A hearing request may be withdrawn only under the following circumstances:
(1) the department receives a written
			 statement from the appellant stating that the request is withdrawn;
			 or
(2) the appellant makes a
			 statement on the record at the hearing withdrawing the request.
New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 519 - Provider Hearings › Section 519.13 - Examination of file before hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If copies of the documentary evidence
			 which the department plans to use at the hearing have not been provided to the
			 appellant, or the appellant's representative, an opportunity to examine such
			 documents, if requested, must be afforded the appellant at the prehearing
			 conference.
(b) The appellant must
			 be afforded an opportunity to examine the audit file at the prehearing
			 conference and to make copies of any relevant documents contained in the file
			 without charge. However, information relating to the selection of the person
			 for audit, investigation notes or other material which may reveal investigation
			 techniques, material prepared for submission to a law enforcement or
			 prosecutorial agency, information concerning law enforcement investigations, or
			 judicial proceedings or confidential sources or confidential information need
			 not be revealed.
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 519.14 - Prehearing conference

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
			 prehearing conference will be held at least seven days in advance of the
			 hearing date at which time each party must disclose the evidence that the party
			 intends to introduce at the hearing, including documentary evidence and
			 identification of witnesses, and consider:
(1) simplification of the issues;
(2) amendments to any pleadings, notices or
			 replies for purposes of clarification;
(3) stipulations, admissions of fact,
			 contents or authenticity of documents, or the accuracy of any photocopy or
			 reproduction intended to be introduced at the hearing;
(4) limitations on the number of witnesses;
			 and
(5) other matters which would
			 expedite the disposition of the proceeding.
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 519.15 - Hearing officer

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
			 hearing officer has all the powers conferred by law to require attendance of
			 witnesses and the production of books and records, and to administer oaths and
			 to take testimony.
(b) The hearing
			 officer will preside over the hearing.
(c) A party to a hearing may make a request
			 to a hearing officer that the hearing officer remove himself or herself from
			 presiding at the hearing.
(1) The grounds for
			 removing a hearing officer are that such hearing officer has:
(i) previously dealt in any way with the
			 substance of the matter which is the subject of the hearing except in the
			 capacity of hearing officer; or
(ii) any interest in the matter, financial or
			 otherwise, direct or indirect, which will impair the independent judgment of
			 the hearing officer; or
(iii)
			 displayed bias or partiality to any party to the hearing.
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 519.16 - Who may be present at the hearing

Current through Register Vol. 46, No. 28, July 10, 2024
The appellant, his/her representative, counsel or other
			   representative of the department, an interpreter if the appellant does not
			   speak English or is deaf and an interpreter has been requested, witnesses for
			   both parties, persons who may be called as witnesses by the hearing officer and
			   such other persons or members of the public as the hearing officer in his/her
			   discretion may admit, are entitled to be present at the hearing. Supervisory
			   staff of the department shall be entitled to observe or to assist the official
			   representative of the department, as necessary for proper supervision and
			   evaluation of the performance of the employee.
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 519.17 - Responsibilities at the hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 The department must provide a representative at the hearing to present the
			 audit file and summarize the case.
(b) The department will provide a brief
			 opening summary of the proceedings had thus far, including:
(1) the names, addresses and ownership or
			 other relationships of persons affected by the action;
(2) the action which prompted the request for
			 the hearing;
(3) a brief
			 description of the facts, evidence and reasons supporting the action including
			 identification of the specific provisions of law or regulations upon which the
			 action was based; and
(4) a copy of
			 its final determination.
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 519.18 - Hearing procedure

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
			 issues and documentation considered at the hearing are limited to issues
			 directly relating to the final determination. An appellant may not raise issues
			 regarding the methodology used to determine any rate of payment or fee, nor
			 raise any new matter not considered by the department upon submission of
			 objections to a draft audit or notice of proposed agency action.
(b) Technical rules of evidence followed in a
			 court of law will not be followed, but evidence must be relevant and
			 material.
(c) Irrelevant and unduly
			 repetitious testimony and cross-examination will be excluded.
(d) The appellant has the burden of:
(1) showing that the determination of the
			 department was incorrect and that all claims submitted and denied were due and
			 payable under the program, or that all costs claimed were allowable;
			 and
(2) proving any mitigating
			 factors affecting the severity of any sanction imposed.
Where the determination is based upon an alleged failure
			   of the provider to comply with generally accepted business, accounting,
			   professional or medical practices or standards of health care, the department
			   must establish the existence of such practice or standard.
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 519.19 - Witnesses

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Witnesses will
			 testify under oath or affirmation and will be subject to
			 cross-examination.
(b) All
			 witnesses will be sworn by the hearing officer and present testimony under
			 direct and cross-examination in view of the hearing officer in order that
			 his/her demeanor may be observed by the hearing officer.
(c) All testimony will be given in response
			 to questions posed directly to the witness by either party or his/her
			 representative on direct or cross-examination, or by the hearing officer where
			 necessary to fully explore the facts of the case. Hypothetical questions need
			 not be used, and expert witnesses may testify directly as to their opinions and
			 reasons without specifying the data upon which they are based or by reference
			 to the department's determination. However, upon cross-examination, experts may
			 be required to specify the data and other criteria supporting their
			 opinions.
(d) Undercover
			 investigators employed by the department may testify behind a screening device
			 or otherwise in order to block the view of the appellant or the witness as
			 he/she testifies and enters and leaves the hearing room. Such a procedure,
			 which to the hearing officer is appropriate under the circumstances, may be
			 employed only when the department determines and states for the record that the
			 safety of the witness may be in jeopardy by his/her unscreened testimony, or
			 that his/her usefulness as an undercover operator may be compromised by his/her
			 unscreened testimony, or that his/her usefulness as an undercover operator may
			 be compromised by his/her being observed by the appellant.
(e) Affidavits or transcripts of prior
			 testimony may be introduced as evidence where the witness is without the State
			 or otherwise unavailable, however, such testimony may not be accepted as sole
			 proof of a fact unless otherwise qualified under an exception to the hearsay
			 rules.
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 519.20 - Hearing record

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A verbatim
			 record of the hearing will be made.
(b) The hearing testimony, the hearing
			 exhibits, the agency determination, the hearing officer's official report
			 containing the substance of what happened at the hearing and the hearing
			 officer's recommendations, all papers and requests filed in the proceeding
			 prior to the close of the hearing, the findings of the hearing officer, and the
			 hearing decision constitute the complete and exclusive record of the
			 hearing.
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 519.21 - Examination of the record after the hearing

Current through Register Vol. 46, No. 28, July 10, 2024
The record of the hearing may be examined by the public
			   at the department's office of administrative hearings during normal business
			   hours. However, material which may identify any person as a recipient of public
			   assistance or care is confidential and can be disclosed only to a party, or a
			   party's representative, and may not be redisclosed.
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 519.22 - Decision after hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
			 written hearing decision will be made by the commissioner or by a person
			 designated to act on behalf of the commissioner and must be based exclusively
			 on the record and testimony introduced at the hearing.
(b) The decision will be issued as promptly
			 as possible, but in any event within 120 days of the conclusion of the hearing
			 or the closing of the record. The decision must describe the issues, recite the
			 relevant facts, the pertinent provisions of law, regulation and State-approved
			 policy, make appropriate findings, determine the issues, state reasons for the
			 determinations, and when appropriate, direct specific action.
(c) The decision is the final agency action
			 and is binding upon the parties.
(d) A copy of the decision will be sent to
			 each of the parties and their representatives, if any.
(e) In the letter transmitting the decision,
			 clear reference must be made to the availability of judicial review by the
			 appellant, if the decision is adverse to the appellant, either in whole or in
			 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 519 - Provider Hearings › Section 519.23 - Decision without hearing

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			 Either party may request that an appeal from a department determination be
			 decided without a hearing. Such request will be granted when it is determined
			 that no unresolved material issue of fact is involved in the case and that the
			 only questions presented are questions of the department's application of the
			 law or its regulations, whether the department failed to perform a duty
			 required by law or whether the department's determination was arbitrary and
			 capricious or an abuse of discretion as to the sanction imposed. A request for
			 a decision without a hearing must be accompanied by sufficient information to
			 permit a determination of whether any unresolved material issue of fact exists,
			 and should contain a full and clear statement of the issue and the party's
			 position on the issue.
(b) Upon
			 receipt of a request for a decision without a hearing which presents, on its
			 face, no factual dispute, a copy of the request and any supporting documents
			 will be sent to the party who did not initiate the request. Within 30 working
			 days of its receipt of the request and documents, the party who did not
			 initiate the request must forward to the hearing officer, and the requesting
			 party, its response containing sufficient information to ensure resolution of
			 the dispute.
(c) The hearing
			 officer will make any further inquiries of the appellant, the appellant's
			 representative and the department which are necessary to resolve the issues
			 involved.
(d) If at any point after
			 a request for a decision without a hearing is received, it appears that there
			 is a material and unresolved issue of fact relating to the issue or issues upon
			 which the hearing has been requested, the hearing officer must inform the
			 parties that a hearing in accordance with the provisions of this Part appears
			 to be necessary to resolve the dispute, and the appellant will then have the
			 option of proceeding with such hearing or withdrawing the request for
			 review.
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 519.24 - Correction of errors

Current through Register Vol. 46, No. 28, July 10, 2024
When a hearing decision has ordered the correction or
			   modification of a departmental action, a payment must be made to the appellant
			   to cover the full amount to which he/she is entitled if an overpayment was
			   improperly recovered and any sanction must be revised in accordance with the
			   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 519.25 - Compliance with decision

Current through Register Vol. 46, No. 28, July 10, 2024
(a) When a
			 decision directs the department to perform specific actions, the department may
			 comply as soon as practicable, but not later than 90 days after receipt of the
			 written decision.
(b) The appellant
			 for whose benefit any direction was given must address any inquiry concerning
			 department compliance to the department's Bureau of Special Hearings which will
			 assure compliance with such direction by any means as may be necessary and
			 appropriate.
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 520 - Tax Refund Offset For Overpayments Of Medical Assistance › Section 520.1 - Scope

Current through Register Vol. 46, No. 28, July 10, 2024
This Part sets forth procedures for providing an
			   individual with notice that tax overpayments owed to an individual taxpayer,
			   estate or trust are being credited to repay overpayments of medical assistance
			   payments owed to the department or a social services district by individuals
			   who are or have been enrolled as providers in the medical assistance program
			   and procedures for such individuals to contest determinations of the department
			   to make such credits of their tax 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 520 - Tax Refund Offset For Overpayments Of Medical Assistance › Section 520.2 - Withholding of State tax overpayments

Current through Register Vol. 46, No. 28, July 10, 2024
The department is entitled to receive overpayments of
			   State tax owed to any individual taxpayer, estate or trust to repay
			   overpayments of medical assistance received by individuals who are or have been
			   enrolled as providers in the medical assistance program, provided that the
			   department (or a social services district) has previously mailed a written
			   determination or notice to the individual identifying the amount and nature of
			   the medical assistance overpayments and requesting repayment of the
			   overpayments in accordance with section
			   520.3  of this
			   Part. The department may not receive overpayments of State tax if a proceeding
			   for administrative or judicial review regarding the overpayments of medical
			   assistance is pending, or if the time for initiation of such a proceeding has
			   not expired.
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 520 - Tax Refund Offset For Overpayments Of Medical Assistance › Section 520.3 - Notice

Current through Register Vol. 46, No. 28, July 10, 2024
When the department has determined that it is entitled to
			   receive overpayments of State tax to repay overpayments of medical assistance,
			   a written notice shall be sent to the individual at the individual's designated
			   payment, correspondence or last known address. The notice shall state:
(a) the basis and specific reasons for the
			 determination of the overpayments;
(b) that medical assistance overpayments are
			 past due;
(c) the specific nature
			 and amount of the overpayments due;
(d) a summary of any previous administrative
			 or judicial proceedings relating to the overpayments in question;
(e) that State law permits the offset of tax
			 overpayments;
(f) that the
			 individual may request in writing a review of the department's determination
			 and proposed referral for offset to an address set forth in the notice within
			 30 days from the date of the notice;
(g) that unless the medical assistance
			 overpayments are paid within 30 days from the date of the notice, such
			 overpayments will be referred to the State Department of Taxation and Finance
			 for offset;
(h) that the individual
			 may present written arguments and evidence in support of any defense to the
			 proposed referral for offset with a request for review, or may appear at a
			 scheduled conference to present oral arguments and written and oral evidence in
			 support of any defense;
(i) that
			 nothing in the notice will be deemed to afford the individual the opportunity
			 to reargue any issue which could have been raised previously in any
			 administrative or judicial proceeding; and
(j) the defenses available to the individual
			 to contest the referral for offset of tax 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 520 - Tax Refund Offset For Overpayments Of Medical Assistance › Section 520.4 - Defenses

Current through Register Vol. 46, No. 28, July 10, 2024
The following defenses may be raised against the proposed
			   referral for offset of tax overpayments, in whole or in part:
(a) the person who received the notice of the
			 tax overpayments offset is not the person identified as owing the medical
			 assistance overpayments;
(b) the
			 overpayments have been paid in full;
(c) the overpayments have been partially paid
			 and the amount due is less than the amount set forth in the notice;
			 or
(d) the person is making current
			 payments to repay the overpayments in accordance with an agreement with the
			 department (or a social services district).
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 520 - Tax Refund Offset For Overpayments Of Medical Assistance › Section 520.5 - Review and determination by the department

Current through Register Vol. 46, No. 28, July 10, 2024
When the department has received a written request for
			   review, the department shall review the arguments and evidence submitted in
			   writing by the individual or the individual may appear at a scheduled
			   conference to present oral arguments and written and oral evidence in support
			   of the defense. The department shall issue a written response to the
			   individual, and the individual's attorney if such information is a matter of
			   record, which will be the final determination of the department. The department
			   is not entitled to receive overpayments of State tax until the time for
			   requesting a review pursuant to section
			   520.3(f) 
			   of this Part has expired or, when such request for a review was timely made,
			   until a written response has been issued by the department advising the
			   individual that retention of the overpayments of State tax by the department is
			   proper.
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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-1 - COMPLIANCE PROGRAMS › Section 521-1.1 - Scope and applicability

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			   Scope. Social Services Law requires certain persons participating in the
			   Medical Assistance (MA) program to adopt and implement programs designed to
			   detect and prevent fraud, waste and abuse in the MA program. Required providers
			   may be able to detect and correct payment and billing mistakes and fraud if
			   required to develop and implement a compliance program. This SubPart sets forth
			   the requirements for establishing and operating effective compliance programs
			   pursuant to section 363-d  of
			   the Social Services Law, the obligation to self-disclose overpayments, and the
			   procedures for reviewing compliance programs.
(b) Applicability. The following persons
			   shall be subject to the provisions of this SubPart, and shall hereinafter be
			   referred to as "
required providers
":
(1) any person subject to the provisions of
			   articles 28 or 36 of the Public Health Law;
(2) any person subject to the provisions of
			   articles 16 and 31 of the Mental Hygiene Law;
(3) any managed care provider or managed long
			   term care plan, which shall hereinafter be collectively, unless otherwise
			   noted, referred to as "
Medicaid managed care organization
" or
			   "
MMCO
;" and
(4)
			   any other person for whom the MA program is, or is reasonably expected by the
			   person to be, a substantial portion of their business operations.
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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-1 - COMPLIANCE PROGRAMS › Section 521-1.3 - Required provider duties

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			   General. Required providers shall, as a condition of receiving payment under
			   the MA program, adopt, implement, and maintain an effective compliance program
			   which satisfies the requirements of this SubPart. The required provider's
			   compliance program may be a component of more comprehensive compliance
			   activities by the required provider so long as the requirements of this SubPart
			   are met. Required providers must implement and maintain a compliance program,
			   adopted pursuant to this SubPart, for the entire period that the person meets
			   the definition of being a required provider.
(b) Record retention. A required provider
			   shall retain all records demonstrating that it has adopted, implemented and
			   operated an effective compliance program and has satisfied the requirements of
			   this SubPart. The required provider shall make available to the department,
			   OMIG, or MFCU upon request, copies of such records. Records shall be retained:
(1) by required providers for a period not
			   less than six (6) years from the date such program was implemented, or any
			   amendments thereto, were made; or
(2) by MMCOs in accordance with the retention
			   periods specified in their contract with the department to participate as
			   MMCOs.
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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-1 - COMPLIANCE PROGRAMS › Section 521-1.5 - Compliance program reviews

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			   Nothing in this SubPart shall preclude or limit the department's ability to
			   determine if a required provider has an effective compliance program.
(b) OMIG may, at any time, review to
			   determine if a required provider has adopted, implemented and maintained a
			   compliance program as required by this SubPart, and to confirm that:
(1) the adopted compliance program satisfies
			   the requirements of this SubPart;
(2) the adopted compliance program has been
			   implemented and that the required provider has continuously operated such
			   program for the entire period under review;
(3) that the required provider met the
			   criteria requiring the adoption, implementation and maintenance of such
			   programs; and
(4) the adopted,
			   implemented and maintained compliance program is effective.
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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-2 - MEDICAID MANAGED CARE FRAUD, WASTE AND ABUSE PREVENTION › Section 521-2.1 - Scope and applicability

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			   Scope. Social Services Law requires managed care providers, including managed
			   long term care plans, to adopt and implement programs designed to detect and
			   prevent fraud, waste and abuse in the MA program. This SubPart sets forth the
			   standards for managed care fraud, waste and abuse prevention programs pursuant
			   to subdivision 39 of section 364-j  of
			   the Social Services Law.
(b)
			   Applicability. This SubPart applies to managed care providers and includes
			   managed care long term care plans, which shall hereinafter be collectively,
			   unless otherwise noted, referred to as "Medicaid managed care organizations" or
			   "MMCO."
(c) Related regulations.
			   Section 98-1.21 of Title 10 and section
			   86.6 of Title 11 set forth
			   requirements related to the establishment and operation, for certain managed
			   care plans, of fraud and abuse prevention plans and programs. MMCOs subject to
			   those sections shall continue to comply with such requirements, provided that,
			   as it pertains to the MMCO's participation in the MA program, the requirements
			   of this SubPart are met. To the extent that any requirements of this SubPart
			   conflict with or are greater than the requirements of those sections, the
			   requirements of this SubPart shall apply to the MMCO.
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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-2 - MEDICAID MANAGED CARE FRAUD, WASTE AND ABUSE PREVENTION › Section 521-2.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For purposes of
			   this SubPart, the terms defined in Parts 504 and 515 of this Title, and SubPart
			   521-1 of this Part, unless noted otherwise, shall apply.
(b) In addition, for the purposes of this
			   SubPart, the following terms have the following meanings:
(1) "
Abuse
" means practices
			   that are inconsistent with sound fiscal, business, medical or professional
			   practices, and which result in unnecessary costs to the Medicaid program,
			   payments for services that were not medically necessary, or payments for
			   services which fail to meet recognized standards for health care. It also
			   includes enrollee practices that result in unnecessary costs to the Medicaid
			   program.
(2) "Fraud" means an
			   intentional deception or misrepresentation made with the knowledge that the
			   deception could result in some unauthorized benefit to the provider,
			   Contractor, Subcontractor, or another person and includes the acts prohibited
			   by section 366-b  of
			   the Social Services Law. It also includes any other act that constitutes fraud
			   under applicable Federal or State 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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-2 - MEDICAID MANAGED CARE FRAUD, WASTE AND ABUSE PREVENTION › Section 521-2.3 - MMCO duties

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			   General. MMCOs shall adopt and implement policies and procedures designed to
			   detect and prevent fraud, waste and abuse. Such policies and procedures shall
			   satisfy the requirements of this SubPart. The MMCO's fraud, waste, and abuse
			   prevention program may be a component of more comprehensive fraud, waste and
			   abuse prevention activities by the MMCO, so long as the requirements of this
			   SubPart are met.
(b) Record
			   retention, access to records and facilities, and cooperation with OMIG,
			   Department and MFCU requests. In addition to the MMCO's record retention
			   obligations under the MMCO's contract with the department to participate as an
			   MMCO, an MMCO shall retain all records demonstrating that it has adopted,
			   implemented and operated a fraud, waste and abuse prevention program which has
			   satisfied the requirements of this SubPart.
(1) The MMCO and its subcontractors shall
			   retain records in accordance with the requirements of its contract with the
			   department to participate as an MMCO.
(2) The MMCO and its subcontractors shall
			   provide to OMIG, the department or their authorized representatives, and MFCU,
			   all records and information requested, in the form requested, and allow access
			   to their facilities at any time. All copies of records must be provided free of
			   charge. The MMCO and its subcontractors shall comply with any additional terms
			   regarding access to records in accordance with the terms of its contract with
			   the department to participate as an MMCO.
(3) The MMCO and its subcontractor shall
			   permit OMIG, the department and MFCU to conduct private interviews of MMCO
			   personnel, its subcontractors and their personnel, witnesses, and enrollees.
			   MMCO personnel, and subcontractors and their personnel must cooperate fully in
			   making MMCO personnel, subcontractors and their personnel available in person
			   for interviews, consultation, grand jury proceedings, pre-trial conferences,
			   hearings, trial and in any other process, including investigation, at the
			   MMCO's and subcontractor's own expense.
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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-2 - MEDICAID MANAGED CARE FRAUD, WASTE AND ABUSE PREVENTION › Section 521-2.4 - Fraud, waste and abuse prevention program requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Compliance program. The MMCO shall adopt,
			   implement and maintain a compliance program that satisfies the requirements of
			   SubPart 521-1 of this Part. The MMCO shall be responsible for ensuring that the
			   requirements of its fraud, waste and abuse prevention program are incorporated
			   into its compliance program. Specifically, the MMCO shall:
(1) incorporate into the written policies and
			   procedures required by subdivision (a) of section
			   521-1.4  of this Part, the MMCO's
			   policies and procedures for preventing, detecting and investigating fraudulent,
			   wasteful or abusive activities by its participating providers, nonparticipating
			   providers, contractors, agents, subcontractors, independent contractors, and
			   any other person the MMCO or its subcontractors pay for ordering, providing,
			   furnishing or arranging for a service to a MA program recipient. The MMCO shall
			   also incorporate any other policies and procedures related to its obligations
			   under this SubPart;
(2) require its
			   designated compliance officer, as required by subdivision (b) of section
			   521-1.4  of this Part, to be
			   responsible, except where noted, for implementing the requirements of this
			   SubPart, and shall be responsible for coordinating with the MMCO's SIU
			   director, where applicable;
(3)
			   include, as part of the training required by subdivision (d) of section
			   521-1.4  of this Part, training of
			   all personnel involved in identifying and evaluating instances of potential
			   fraud, waste and abuse; and
(4)
			   include, as part of its auditing and monitoring activities as required by
			   subdivision (g) of section
			   521-1.4  of this Part, the
			   requirements of subdivision (c) of 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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-3 - SELF-DISCLOSURE PROGRAM › Section 521-3.1 - Scope and applicability

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
			   Scope.
(1) Subdivision 6 of the section 363-d  of
			   the Social Services Law requires persons who have received an overpayment under
			   the MA program to report, return and explain the overpayment to the department
			   and the Office of Medicaid Inspector General ("OMIG").
(2) A person satisfies their obligation to
			   report, return and explain by making a disclosure through OMIG's
			   Self-Disclosure Program, complying with the requirements as specified in
			   section 521-3.4  of this SubPart, and
			   returning the overpayment and interest to the department in accordance with the
			   provisions of section
			   521-3.5  of this SubPart.
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 521 - Fraud, Waste and Abuse Prevention › Subpart 521-3 - SELF-DISCLOSURE PROGRAM › Section 521-3.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For purposes of
			   this SubPart, the terms defined in Parts 504 and 515 of this Title, and SubPart
			   521-1 of this Part, except as otherwise noted in this SubPart, shall
			   apply.
(b) In addition, for the
			   purposes of this SubPart, the following terms have the following meanings:
(1) "
Managed long term care
			   plan
" means an entity that has received a certificate of authority
			   pursuant to section 4403-f  of
			   the Public Health Law to provide or arrange for health and long term care
			   services on a capitated basis for a population which the plan is authorized to
			   enroll.
(2) "
MMCO
"
			   means:
(i) a managed care provider as defined
			   in in subdivision 1 of section 364-j  of
			   the Social Services Law; and
(ii) a
			   managed long term care plan.
(3) "
Overpayment
" has the
			   same meaning as used in subdivision (c) of section
			   518.1  of this Title.
(4) "
Person
" means:
(i) a provider as defined in section
			   504.1  of this Title;
(ii) an MMCO, and any subcontractors or
			   network providers of an MMCO; and
(iii) does not include MA program
			   recipients.
(5)
			   "
Self-Disclosure and Compliance Agreement
" or
			   "
SDCA
" means the stipulation of settlement between OMIG and a
			   person who agrees to repay the MA program the amount of the overpayment and
			   interest in accordance with the provisions of section
			   518.4  of this Title through
			   installment payments and/or agrees to implement corrective action to prevent
			   recurrence of the conduct giving rise to the overpayment.