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 516.1 - Scope and definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Scope.
			 Social Services Law authorizes the imposition of monetary penalties for certain
			 violations of the Medical Assistance (MA) program. This Part shall apply to
			 monetary penalties imposed by the Office of the Medicaid Inspector General
			 (OMIG) pursuant to sections 145-b (4), 363-d, and 364-j (38)  of the Social
			 Services Law. Nothing in this Part shall preclude or limit the Department of
			 Health's ability to impose or levy fines or penalties or take any
			 administrative actions under other provisions of this Title.
(b) Definitions. For purposes of sections 145-b (4), 363-d, and 364-j (38)  of the Social Services Law, and this Part, the
			 terms defined in Parts 504, 515 and 521 of this Title, except as may be
			 provided for herein, and the following terms apply:
(1) "Encounter" means all encounter records,
			 or adjustments to previously submitted records, which the managed care provider
			 or managed long term care plan (MLTCP) has received and processed from provider
			 encounter or claim records of all contracted services rendered to an enrollee
			 of the managed care provider or MLTCP in the current or any preceding
			 month.
(2) "Failure to grant timely
			 access to records and facilities" means the failure to produce or make
			 available for review, copying, and inspection requested material, or to provide
			 access to facilities upon reasonable notice by the deadline specified in the
			 written request made by OMIG, the department, or the deputy attorney general
			 for Medicaid Fraud Control.
(3)
			 "Item or service" means all medical care, services or supplies claimed to have
			 been provided or furnished to a recipient of the MA program and which is listed
			 in an itemized claim for payment or encounter.
(4) "Office of the Medicaid Inspector
			 General" or "OMIG" means the independent office within the department
			 established pursuant to Title 3 of Article 1 of the New York State Public
			 Health Law.
(5) "Person" is as
			 defined in Part 504 of this Title, except for monetary penalties imposed
			 pursuant to section 145-b (4)  of the Social
			 Services Law. For purposes of section 145-b (4)  of the Social
			 Services Law "person" is as defined in that section.
(6) "Standards of generally accepted
			 practice" means the degree of knowledge, skill and diligence possessed by, or
			 required of, the average member of the profession or specialty which is
			 practiced. Standards of generally accepted practice also include those
			 practices which are accepted as effective and appropriate by the medical and
			 scientific community of this State.
(7) "Standards of the MA program" include but
			 are not limited to the standards set forth in the rules, regulations, and
			 official directives of the department.
(8) "Substantial number of cases" means five
			 percent or more of those claims, encounters, or cases identified in any audit,
			 investigation or review, or any sample of cases which were the subject of an
			 audit or otherwise reviewed by the department and for which claims were
			 submitted by a person for payment under the MA program.