Part 540 - AUTHORIZATION OF MEDICAL CARE

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Statutory Authority: 
Social Services Law, Sections 20, 34, 363-a, 364, 365-a, 367-b, 368-a, 368-b

Section 540.1 - Authorization as basis for payment for medical assist

Section 540.1 Authorization as basis for payment for medical assistance. Vendor payments for medical care and other items of medical assistance shall not be made unless such care or other items of assistance have been furnished on the basis of the appropriate authorization prescribed by the rules of the board and regulations of the department.

 

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Section 540.2 - Limitations on nonmedical assistance emergency hospital care.

540.2 Limitations on nonmedical assistance emergency hospital care.

(a) The provisions of this section shall not apply to nor limit payment of costs of care in the cases of emergency hospital admissions when the costs of care are subject to payment as medical assistance. However, in cases of emergency admissions of persons who have been determined to be eligible for medical assistance, the hospital shall give the five days' notice required by subdivision (d) of section 505.4 of this Subchapter.

(b) Emergency hospital care which may be provided without the specific prior authorization of the public welfare official shall be limited to those instances in which immediate admission is essential. Notification shall be given to the public welfare official within five days, Saturdays, Sundays and legal holidays excepted. Payment from public funds after such notification is subject to acceptance of liability by the public welfare official.

 

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Section 540.3 - Drug prescriptions.

540.3 Drug prescriptions. Drug prescriptions may be rendered on order of a physician at any time in the course of attendance on a case and without specific prior authorization for the particular prescription.

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Section 540.4 - Notification to public welfare official for medical services.

540.4 Notification to public welfare official for medical services.

(a) General. (1) Notification by a physician, dentist, hospital or other vendor of a request for authorization to furnish items of medical assistance shall be furnished to the appropriate public welfare official for the purpose of receiving advance authorization to render service, where such advance authorization is required by rules of the board or regulations of the department, except by a hospital in case of emergency as defined in section 540.2 of this Part, in which case notification shall be given within the time specified in that section.

(2) Notification shall consist at least of:

(i) case and patient (if other than name of household head), identification date and place of services to be rendered, and/or already rendered if emergent;

(ii) preliminary diagnosis;

(iii) estimated scope of services to be rendered (number of visits, and/or special auxiliary services required);

(iv) name and address of physician, dentist, hospital or other vendor providing services;

(v) identification of vendors of special auxiliary services requested if known.

(3) Such notification may be furnished in writing by the professional attendant or vendor or may be made verbally, in which event the public agency shall reduce the contents of the notification to writing at once. For either such purpose, the agency shall utilize a form providing the minimum content of section A of the illustrative form M-1 contained in the instructions of the department.

 

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Section 540.5 - Authorization by public welfare officials.

540.5 Authorization by public welfare officials. (a) General. Whenever prior authorization for any item of medical assistance is required, the public welfare official shall give notification to the vendor in accordance with the requirements of this section.

(1) The public welfare official shall either accept liability for the cost of the medical care requested by issuing an authorization to the vendor containing the minimum essentials listed below, or he shall deny responsibility by notifying the vendor in writing of his rejection of the notification. It is desirable that the acceptance of the notification be issued to the vendor in writing, but, if the public welfare official prefers, he may arrange with the vendor that acceptance of liability may be assumed unless a notice of rejection is received by the vendor. Whether or not the acceptance of liability is issued to the vendor in writing, a written authorization containing the minimum essentials listed below shall be forwarded by the authorizing official to the disbursing unit of the public welfare agency, the information contained in such written authorization becoming the basis for payment by the disbursing unit of the agency to the medical vendor. Such authorizations shall be subject to the same limitations and control as are specified in section 540.6 of this Part.

(2) Decision as to acceptance or rejection of notification and request for authorization shall be made as promptly as possible by the public welfare official.

(3) If the notification and request for authorization is accepted by the public welfare official, the authorization to the vendor (or vendors) shall contain, as a minimum, the following information:

(i) case identification and patient designation;

(ii) effective date of services for which public welfare official assumes liability;

(iii) expiration date of authorization;

(iv) volume of service authorized;

(v) type, character or nature of services authorized;

(vi) vendor authorized to provide such services;

(vii) source of payment (if other than agency);

(viii) signature of authorizing official and date of issuance;

(ix) signature of supervisor of medical services, when required by nature of service.

(4) The agency shall utilize a form of authorization containing such minimal information, as illustrated in section B of illustrative form M-1, contained in the instructions of the department.

(5) (i) After May 14, 1976, the local social services official shall authorize medical assistance payments only after obtaining documentation of the following actions for persons admitted on or after May 14, 1976 to skilled nursing facilities holding title XVIII provider agreements:

(a) that the Commissioner of Health or his designee has approved admission and continued stay in a skilled nursing facility; and

(b) that the admitting facility has prepared written justification of the decision not to make application to Medicare because of the patient's apparent technical ineligibility; or

(c) that application has been made for Medicare benefits and rejected as being ineligible; and

(d) that reconsideration of the Medicare rejection has been initiated or, when the skilled nursing facility agrees with Medicare's reasons for rejecting, a written justification of their agreement has been submitted to the local medical director.

(ii) Skilled nursing facilities shall not be required to initiate requests for reconsideration in cases where they agree with Medicare's rejection. The Commissioner of Health or his designee, however, shall review the skilled nursing facility's justifications for agreeing with Medicare. In those instances in which the Commissioner of Health or his designee disagrees with the Medicare rejection, the social services official shall require the skilled nursing facility to initiate a reconsideration of Medicare's decision.

(iii) Should the Medicare reconsideration process fail to reverse the initial rejection, the local social services district shall assume responsibility for insuring that a Medicare appeal is initiated in each appropriate instance.

(iv) Appeals, when deemed to be appropriate, must be initiated within 14 calendar days of the date of the fiscal intermediary's notification that the reconsideration process had failed to reverse the original decision.

 

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Section 540.6 - Billing for medical assistance.

540.6 Billing for medical assistance.

(a) (1) Claims for payment for medical care, services or supplies furnished by any provider under the medical assistance program must be initially submitted within 90 days of the date the medical care, services or supplies were furnished to an eligible person to be valid and enforceable against the department or a social services district, unless the provider's submission of the claims is delayed beyond 90 days due to circumstances outside of the control of the provider. Such circumstances include but are not limited to attempts to recover from a third-party insurer, legal proceedings against a responsible third-party or the recipient of the medical care, services or supplies or delays in the determination of client eligibility by the social services district. All claims submitted after 90 days must be accompanied by a statement of the reason for such delay and must be submitted within 30 days from the time submission came within the control of the provider, subject to the limitations of paragraph (3) of this subdivision.

(2) Any claim returned to a provider due to data insufficiency or claiming errors may be resubmitted by the provider upon proper completion of the claim in accordance with the claims processing requirements of the department within 60 days of the date of the notification to the provider advising the provider of such insufficiency or invalidity. Any returned claim not correctly resubmitted within 60 days or on the second resubmission is neither valid nor enforceable against the department or a social services district.

(3) Notwithstanding paragraphs (1) and (2) of this subdivision to the contrary:

(i) all claims for payment for medical care, services or supplies furnished by non-public providers under the medical assistance program must be finally submitted to the department or its fiscal agent and be payable within two years from the date the care, services or supplies were furnished in order to be valid and enforceable as against the department or a social services district; and

(ii) all claims for payment for medical care, services or supplies furnished by public providers must be finally submitted to the department or its fiscal agent and be payable within two years from the date the care, services or supplies were furnished (or within such other period as agreed by the department and the public provider for payments initially made by the public provider under a program other than the medical assistance program) in order to be valid and enforceable as against the department or a social services district.

(4) For purposes of this subdivision, a claim is considered submitted upon its receipt by the department or its fiscal agent.

(b) (1) The department, on the dates specified, will assume, for the social services district comprising the city of New York, payment responsibilities for all claims of the following specified providers of medical care, services and supplies authorized to be provided under title II of article 5 of the Social Services Law (medical assistance for needy persons) for the care, services and supplies rendered on and after the date specified for the assumption of payment responsibilities by the department:

(i) Practitioner--which include the following, on November 1, 1977:

(a) Physician.

(ii) Clinics--which include the following, on November 1, 1977:

(a) Hospital emergency room;

(b) Hospital outpatient (other than dental service);

(c) Diagnostic and treatment center (clinic, free standing);

(d) Psychiatric clinic;

(e) Hospital psychiatric care (outpatient).

(iii) Pharmacies--which include the following, on April 1, 1978:

(a) Prescription drugs;

(b) Nonprescription drugs;

(c) Medical supplies, including sickroom supplies, provided by the pharmacy.

(iv) Hospitals--which include the following, on June 1, 1978:

(a) Inpatient hospitals;

(b) Private psychiatric hospitals.

(v) Dentists, dental schools and dental clinics, on September 1, 1978.

(vi) Laboratories, on September 1, 1978.

(vii) Skilled nursing facilities, which include nonoccupant care provided therein pursuant to Subchapter C of Title 10 of the Official Compilation of Codes, Rules and Regulations (Parts 780 through 782), on December 1, 1978.

(viii) Health related facilities, on December 1, 1978:

(a) excluding those facilities operated by the Office of Alcoholism and Substance Abuse in the New York State Department of Mental Hygiene; and

(b) excluding any facilities for the mentally retarded (HRF or ICF) whether operated privately or by the New York State Department of Mental Hygiene.

(ix) Health maintenance organizations, on January 1, 1979.

(x) Health insurance premiums, including prepaid group health insurance plans, on January 1, 1979.

(xi) Medical equipment dealers, including medical and surgical supply dealers, on January 15, 1979. Institutions supplying home dialysis equipment to kidney dialysis patients on April 1, 1981.

(xii) Prosthetic and orthotic appliance dealers, on January 15, 1979.

(xiii) Hearing aid dealers, on January 15, 1979.

(xiv) Transportation services, on January 15, 1979.

(xv) Home health agencies, on January 15, 1979.

(xvi) Child care agencies, on February 1, 1979.

(xvii) Optometrists, on February 1, 1979.

(xviii) Opticians and optical dispensers, on February 1, 1979.

(xix) Referred ambulatory care, on December 1, 1978.

(xx) (Repealed)

(xxi) Clinical psychologists, on March 1, 1979.

(xxii) Private psychiatric--inpatient, on March 1, 1979.

(xxiii) Nursing home facilities administered by Bureau of Medical Assistance-New York City, on March 1, 1979.

(xxiv) Independent speech and physical therapists.

(xxv) Occupational therapists.

(xxvi) Medical equipment dealers, including medical and surgical supply dealers, on January 15, 1979.

(xxvii) Prosthetic and orthotic appliance dealers, on January 15, 1979.

(xxviii) Hearing aid dealers, on January 15, 1979.

(xxix) Transportation services, on January 15, 1979.

(xxx) Home health agencies, on February 1, 1979.

(xxxi) Intermediate care facilities--mentally retarded (private and day care), on February 1, 1979.

(xxxii) Institutions supplying prescription drugs, nonprescription drugs and medical supplies to kidney dialysis patients on April 1, 1981.

(2) The above specified providers of medical care, services and supplies will submit claims to the district comprising the city of New York for all items of care, services and supplies furnished prior to date specified for the assumption of payment responsibilities by the department; and thereafter, such providers will submit claims for medical care, services and supplies furnished after such date to the department for all items of medical care, services and supplies.

(3) Providers rendering medical care, services and supplies to recipients of Medicaid who have received their authorization from the following specified counties shall bill the department for the specified care, services and supplies rendered on and after the date or dates respectively specified for such county:

(i) Chemung County: All care, services and supplies--August 1, 1979;

(ii) Washington County: All care, services and supplies--August 1, 1979;

(iii) Nassau County: All care, services and supplies--August 1, 1979, or such later date, to be specified by the commissioner, which shall in no event be later than November 1, 1979. The commissioner shall give at least 30 days' notice of the date specified in this subparagraph;

(iv) Livingston County: All care, services and supplies--September 1, 1980;
(v) Ontario County: All care, services and supplies--September 1, 1980;

(vi) Schuyler County: All care, services and supplies--September 1, 1980;

(vii) Seneca County: All care, services and supplies--September 1, 1980;

(viii) Steuben County: All care, services and supplies--September 1, 1980;

(ix) Wayne County: All care, services and supplies--September 1, 1980;

(x) Yates County: All care, services and supplies--September 1, 1980;

(xi) Monroe County: All care, services and supplies--November 1, 1980;

(xii) Dutchess County: All care, services and supplies--March 1, 1981;

(xiii) Orange County: All care, services and supplies--March 1, 1981;

(xiv) Putnam County: All care, services and supplies--March 1, 1981;

(xv) Rockland County: All care, services and supplies--March 1, 1981;

(xvi) Sullivan County: All care, services and supplies--March 1, 1981;

(xvii) Ulster County: All care, services and supplies--March 1, 1981;

(xviii) Westchester County: All care, services and supplies--May 1, 1981;

(xix) Warren County: All care, services and supplies--May 1, 1981;

(xx) Saratoga County: All care, services and supplies--May 1, 1981;

(xxi) Fulton County: All care, services and supplies--May 1, 1981;

(xxii) Montgomery County: All care, services and supplies--May 1, 1981;

(xxiii) Schenectady County: All care, services and supplies--May 1, 1981;

(xxiv) Schoharie County: All care, services and supplies--May 1, 1981;

(xxv) Albany County: All care, services and supplies--May 1, 1981;

(xxvi) Rensselaer County: All care, services and supplies--May 1, 1981;

(xxvii) Greene County: All care, services and supplies--May 1, 1981;

(xxviii) Columbia County: All care, services and supplies--May 1, 1981;

(xxix) Cortland County: All care, services and supplies--July 1, 1981;

(xxx) Madison County: All care, services and supplies--July 1, 1981;

(xxxi) Oneida County: All care, services and supplies--July 1, 1981;

(xxxii) Onondaga County: All care, services and supplies--September 1, 1981;

(xxxiii) Oswego County: All care, services and supplies--July 1, 1981;

(xxxiv) Cayuga County: All care, services and supplies--July 1, 1981;

(xxxv) Broome County: All care, services and supplies--September 1, 1981;

(xxxvi) Chenango County: All care, services and supplies--September 1, 1981;

(xxxvii) Delaware County: All care, services and supplies--September 1, 1981;

(xxxviii) Otsego County: All care, services and supplies--September 1, 1981;

(xxxix) Tioga County: All care, services and supplies--September 1, 1981;

(xl) Tompkins County: All care, services and supplies--September 1, 1981;

(xli) Allegany County: All care, services and supplies--October 1, 1981;

(xlii) Cattaraugus County: All care, services and supplies--October 1, 1981;

(xliii) Chautauqua County: All care, services and supplies--October 1, 1981;

(xliv) Genesee County: All care, services and supplies--October 1, 1981;

(xlv) Niagara County: All care, services and supplies--October 1, 1981;

(xlvi) Orleans County: All care, services and supplies--October 1, 1981;

(xlvii) Wyoming County: All care, services and supplies--October 1, 1981;

(xlviii) Clinton County: All care, services and supplies--December 1, 1981;

(xlix) Essex County: All care, services and supplies--December 1, 1981;

(l) Franklin County: All care, services and supplies--December 1, 1981;

(li) Hamilton County: All care, services and supplies--December 1, 1981;

(lii) Herkimer County: All care, services and supplies--December 1, 1981;

(liii) Jefferson County: All care, services and supplies--December 1, 1981;

(liv) Lewis County: All care, services and supplies--December 1, 1981;

(lv) St. Lawrence County: All care, services and supplies--December 1, 1981;

(lvi) Suffolk County: All care, services and supplies--January 1, 1981; and

(lvii) Erie County: All care, services and supplies--February 1, 1982.

(c) The uniform billing form (UBF-1) shall be used for all acute care hospital inpatient bills for a patient's stay whose admission to the hospital occurred on or after the appropriate implementation date as specified by the State Department of Social Services.

(d) Providers rendering personal care services under a contractual arrangement with local social services districts as described in section 505.14 of this Title shall bill the department for the specified service rendered on and after the date(s) respectively specified for such social services district as follows:

(1) Chenango County: All personal care services--July 1, 1985;

(2) Genesee County: All personal care services--July 1, 1985;

(3) Livingston County: All personal care services--July 1, 1985;

(4) Niagara County: All personal care services--July 1, 1985;

(5) Ontario County: All personal care services--July 1, 1985;

(6) Orleans County: All personal care services--July 1, 1985;

(7) Wyoming County: All personal care services--July 1, 1985;

(8) Clinton County: All personal care services--August 1, 1985;

(9) Essex County: All personal care services--August 1, 1985;

(10) Hamilton County: All personal care services--August 1, 1985;

(11) Jefferson County: All personal care services--August 1, 1985;

(12) Lewis County: All personal care services--August 1, 1985;

(13) St. Lawrence County: All personal care services--August 1, 1985;

(14) Yates County: All personal care services--September 1, 1985;

(15) Cayuga County: All personal care services--September 1, 1985;

(16) Cortland County: All personal care services--September 1, 1985;

(17) Schuyler County: All personal care services--September 1, 1985;

(18) Seneca County: All personal care services--September 1, 1985;

(19) Tompkins County: All personal care services--September 1, 1985;

(20) Wayne County: All personal care services--September 1, 1985;

(21) Cattaraugus County: All personal care services--October 1, 1985;

(22) Chautauqua County: All personal care services--October 1, 1985;

(23) Chemung County: All personal care services--October 1, 1985;

(24) Franklin County: All personal care services--October 1, 1985;

(25) Steuben County: All personal care services--October 1, 1985;

(26) Tioga County: All personal care services--October 1, 1985;

(27) Columbia County: All personal care services--November 1, 1985;

(28) Dutchess County: All personal care services--November 1, 1985;

(29) Erie County: All personal care services--November 1, 1985;

(30) Orange County: All personal care services--November 1, 1985;

(31) Putnam County: All personal care services--November 1, 1985;

(32) Rensselaer County: All personal care services--November 1, 1985;

(33) Rockland County: All personal care services--November 1, 1985;

(34) Sullivan County: All personal care services--November 1, 1985;

(35) Ulster County: All personal care services--November 1, 1985;

(36) Madison County: All personal care services--December 1, 1985;

(37) Otsego County: All personal care services--December 1, 1985;

(38) Oswego County: All personal care services--December 1, 1985;

(39) Saratoga County: All personal care services--December 1, 1985;

(40) Warren County: All personal care services--December 1, 1985;

(41) Washington County: All personal care services--December 1, 1985;

(42) Delaware County: All personal care services--January 1, 1986;

(43) Fulton County: All personal care services--January 1, 1986;

(44) Greene County: All personal care services--January 1, 1986;

(45) Herkimer County: All personal care services--January 1, 1986;

(46) Montgomery County: All personal care services--January 1, 1986;

(47) Oneida County: All personal care services--January 1, 1986;

(48) Schoharie County: All personal care services--January 1, 1986; and

(49) New York City: All personal care services--July 1, 1986.

(e) (1) As a condition of payment, all providers of medical assistance must take reasonable measures to ascertain the legal liability of third parties to pay for medical care and services.

(2) No claim for reimbursement shall be submitted unless the provider has:

(i) investigated to find third-party resources in the same manner and to the same extent as the provider would to ascertain the existence of third-party resources for individuals for whom reimbursement is not available under the medical assistance program; and

(ii) sought reimbursement from liable third parties.

(3) Each medical assistance provider shall:

(i) request the medical assistance recipient or his representatives to inform the provider of any resources available to pay for medical care and services;

(ii) make claims against all resources indicated on a Medicaid identification card or communicated to the provider via the electronic Medicaid eligibility verification system, via the medical assistance information and payment system (MMIS) toll-free inquiry telephone number of via the MMIS transaction telephone system, and all resources which the provider has discovered, prior to submission of any claim to the medical assistance program;

(iii) continue investigation and attempts to recover from potential third-party resources after submission of a claim to the medical assistance program to at least the same extent that such investigations and attempts would occur in the absence of reimbursement by the medical assistance program;

(iv) if the provider is informed of the potential existence of any third-party resources by an official of the medical assistance program, or by any other person who can reasonably be presumed to have knowledge of a probable source of third-party resources, investigate the possibility of making a claim to the liable third party and make such claim as is reasonably appropriate; and

(v) take any other reasonable measures necessary to assure that no claims are submitted to the medical assistance program that could be submitted to another source of reimbursement.

(4) Any reimbursement the provider recovers from liable third parties shall be applied to reduce any claims for medical assistance submitted for payment to the medical assistance program by such provider or shall be repaid to the medical assistance program within 30 days after thirdparty liability has been ascertained; when a claim has been submitted to a third party whose liability was ascertained after submission of a claim to the medical assistance program the provider must make reimbursement to the medical assistance program within 30 days after the receipt of reimbursement by the provider from a liable third party.

(5) A provider of medical assistance shall not deny care or services to a medical assistance recipient because of the existence of a thirdparty resource to which a claim for payment may be submitted in accordance with this subdivision.

(6) A provider of medical assistance must review and examine information relating to available health insurance and other potential thirdparty resources for each medical assistance recipient to determine if a health insurance identification card or any other information indicates that prior or other approval is required for non-emergency, post-emergency, non-maternity, hospital, physician or other medical care, services or supplies. If approval is required as a condition of payment or reimbursement by an insurance carrier or other liable third party, the provider must obtain for the recipient, or ensure that the recipient has obtained, any necessary approval prior to submitting any claims for reimbursement from the medical assistance program. The provider must comply with all Medicare or other third-party billing requirements and must accept assignment of the recipient's right to receive payment or must acquire any other rights of the recipient necessary to ensure that no reimbursement is made by the medical assistance program when the costs of medical care, services or supplies could be borne by a liable third party. If a provider fails to comply with these conditions, any reimbursement received from the medical assistance program in violation of the provisions of this paragraph must be repaid to the medical assistance program by such provider. No repayment will be required if the provider can produce acceptable documentation to the department that the provider reasonably attempted to ascertain and satisfy any conditions of approval or other claiming requirements of liable third-party payors in the same manner and to the same extent as the provider would for individuals for whom reimbursement is not available under the medical assistance program, as described in paragraphs (1) through (5) of this subdivision.

(7) A provider of medical assistance who becomes aware, or reasonably should have become aware, of available health insurance or other potential third party resources that can be claimed from a liable third party by the provider as an agent of a social services official in accordance with the provisions of Part 542 of this Title, must submit a claim for such payment to the liable third party in the manner described in Part 542, except that a provider will not be required to submit such a claim to a liable third party when the claim is for prenatal care for pregnant women or preventive pediatric services (including early and periodic screening, diagnosis and treatment services). If a provider fails to submit such a claim as required by this paragraph, reimbursement for such claim will not be made by the medical assistance program and any reimbursement received in violation of the provisions of this paragraph must be repaid to the medical assistance program by such provider. If a provider has satisfied the requirements described in paragraphs (1) through (6) of this subdivision, no repayment will be required if the provider can produce documentation acceptable to the department that the provider reasonably attempted to ascertain whether such claim could be submitted in the manner described in Part 542 of this Title. If a provider submits a claim in accordance with the provisions of Part 542 of this Title and all or a portion of such claim is rejected by the liable third party through no fault of the provider, that portion of the claim that is so rejected may be submitted to the medical assistance program for payment.

 

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Section 540.7 - Requirements for billing.

540.7 Requirements for billing. (a) All bills for medical care, services and supplies shall contain:

(1) patient name, case number and date of service;

(2) itemization of the volume and specific types of care, services and supplies provided (including for a physician, his final diagnosis, and for drugs, the prescription filled);

(3) the unit price and total cost of the care, services and supplies provided;

(4) vendor name and address;

(5) the social security number or employer identification number of the vendor in accordance with the following:

(i) When the provider of services is in solo practice, or when the provider of supplies is in business by himself, identification shall be by social security number.

(ii) When the provider of services is in other than solo practice, identification shall depend upon the group's billing practices; e.g., where the billing is by the individual, then identification shall be by social security number.

(iii) Where billing is by a partnership or a corporation, then identification shall be by employer identification number.

(iv) Where billing is by a medical facility (e.g., hospital, skilled nursing facility or health-related facility) and such billing includes the cost of care provided by a physician, the name and social security number of the physician shall be separately stated;

(6) for the initial billing only, the following documentation for persons admitted on or after May 14, 1976 to skilled nursing facilities holding title XVIII provider agreements shall be required. Claims for medical assistance payments shall not be processed if any element of the required documentation as herein provided is not submitted by the skilled nursing home operator:

(i) a copy of the New York State Health Department's Long-Term Care Placement Form (DMS-1) or equivalent, properly and legibly completed, which was submitted for skilled nursing coverage under title XVIII;

(ii) additional forms and documents necessary to assess the patient's medical condition or need for skilled nursing home care and services and determined by the Commissioner of Health or his designee;

(iii) a written justification of the facility's decision not to submit to Medicare because of the patient's apparent technical ineligibility for coverage;

(iv) the official Medicare denial notice received from the Bureau of Health Insurance or its fiscal intermediary for this purpose; and

(v) a copy of the request for reconsideration for skilled nursing facility coverage submitted to Medicare; or, in cases where the skilled nursing facility agrees with the Medicare decision, a copy of the skilled nursing facility's justification for agreeing with the Medicare rejection;

(7) in the case of hospital bills submitted to the local department of social services for inpatient, general hospital care, services and supplies, the hospital shall maintain on file the notification of coverability made by the Commissioner of Health or his authorized representative attesting to the appropriateness and necessity of such care, services and supplies in accordance with Part 505 of this Subchapter. No billing for payment shall be made for care, services or supplies for any period of time for which coverability has not been determined by the Commissioner of Health or his designee;

(8) a dated certification by the provider that the care, services and supplies itemized have in fact been furnished; that the amounts listed are due and owing and that, except as noted, no part thereof has been paid; that payment of fees and rates made in accordance with established schedules is accepted as payment in full for the care, services and supplies provided; that there has been compliance with title VI of the Federal Civil Rights Act of 1964 in furnishing care, services and supplies without discrimination on the basis of race, color or national origin; that such records as are necessary to disclose fully the extent of care, services and supplies provided to individuals under the New York State Medicaid program will be kept for a period of not less than six years from the date of payment unless otherwise required by regulation, and information will be furnished regarding any payment claimed therefor as the local social services agency or the State Department of Social Services may request; and that the provider understands that payment and satisfaction of this claim will be from Federal, State and local public funds and that he or she may be prosecuted under applicable Federal and State laws for any false claims, statements or documents, or concealment of a material fact provided, however, that each bill need not contain the dated certification required by this paragraph in cases where the care, services or supplies (other than the services of a clinical laboratory) were furnished in a Canadian province or in a state other than the State of New York by a provider with a principal place of business outside the State of New York so long as the provider has previously filed with the department a certification containing all of the provisions required by this paragraph which will be applicable to all bills to be submitted by the provider during the period of the provider's participation in the medical assistance program.

(9) (i) Prior to payment of a bill for a service directly related to a sterilization or a hysterectomy, the State agency must be in possession of the appropriate documentation.

(ii) For sterilization this is the DSS 3134, "Sterilization Consent Form"; for hysterectomies, the DSS 3113, "Acknowledgment of Receipt of Hysterectomy Information."

(10) In the case of bills for physician services, physicians are required to maintain complete, legible records in English for each patient treated. Medical records shall include at a minimum, but not be limited to, the following:

(i) the full name, address and medical assistance program identification of each patient examined and/or treated in the office for which a bill is presented;

(ii) the date of each patient visit;

(iii) the patient's chief complaint or reason for each visit;

(iv) the patient's pertinent medical history as appropriate to each visit, and findings obtained from any physical examination conducted that day;

(v) any diagnostic impressions made for each visit;

(vi) a recording of any progress of a patient, including patient response to treatment;

(vii) a notation of all medication dispensed, administered or prescribed, with the precise dosage and drug regimen for each medication dispensed or prescribed;

(viii) a description of any X-rays, laboratory tests, electrocardiograms or other diagnostic tests ordered or performed, and a notation of the results thereof;

(ix) a notation as to any referral for consultation to another provider or practitioner, a statement as to the reason for, and the results of such consultations;

(x) a statement as to whether or not the patient is expected to return for further treatment, the treatment planned, and the time frames for return appointments;

(xi) a chart entry giving the medical necessity for any ancillary diagnostic procedure; and

(xii) all other books, records and other documents as are necessary to fully disclose the extent of the care, services and supplies provided.

(b) Bills may represent individual billing for each case served, or may represent multiple billing for a number of cases at one time, depending upon the regulations which the public welfare district shall establish. Such regulations will be governed by the plan of medical payments elected by the district pursuant to State regulations with respect thereto. In the case of multiple billing, supporting details for each service provided to each patient must be attached to the bill, unless the description of services rendered on the face of the bill is complete. (For example, a multiple bill for drug prescriptions furnished would ordinarily be supported by copies of the prescriptions, except in the unlikely situation where a druggist lists the details of a prescription on the face of the bill itself.)

 

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Section 540.8 - Verification, payment and recording of medical bills.

540.8 Verification, payment and recording of medical bills. (a) The public welfare official, on receipt of bills rendered by vendors of medical assistance, shall cause such bills to be classified on the basis of State or local charge status of each recipient and the charges relative thereto and a verification of such bills within the scope and limitations of authorizations issued by the public welfare official for the services billed, and with the schedule of fees and rates promulgated by the public welfare official for vendor services. Where the fees and rates promulgated by the public welfare official exceed ceiling limits set by State regulations, the amount by which the charges billed exceed the State limits shall be identified and segregated for purposes of preparing proper claims for State aid.

(1) Verification of bills against authorization and against the schedule of fees and rates includes: verification of mathematical accuracy of billing; conformity with all billing requirements (properly signed, etc.); verification of technical or professional qualifications where such may affect the fee to be allowed; verification of mileage rates and total charges; etc. (Verification of such scope may necessitate provisions of internal agency examination of billings by clerical personnel, in part, and by professional personnel, in part.)

(b) The method of payment used by the public welfare official to settle approved and verified bills for medical services shall be in accordance with the provisions governing the particular plan of payment for medical services in effect in the district pursuant to State regulations with respect thereto.

(c) In issuing payments for medical services rendered, the public welfare official may find it advisable to identify the payment instrument with the particular services for which payment is being made.

(1) Where bills from an individual vendor for an individual case are settled by a one-payment transaction, the payment instrument may show an identification of the services being paid for in lieu of separate notification.

(2) Where bills of a vendor for medical services covering a group of cases are settled by a one-payment transaction, it will be desirable to furnish a statement of the services and cases covered by the payment transaction in order to reconcile the items being paid with the items billed for.

(d) Upon notification by the department that a nursing home company subject to the provisions of article 28-A of the Public Health Law, has failed to make a required payment in accordance with its mortgage with the New York State Housing Finance Agency or the New York State Medical Care Facilities Finance Agency, the public welfare official shall take such administrative steps as may be required by the department to insure that payment of all claims for services rendered by the nursing home company under the medical assistance program is made payable to the nursing home company's operating escrow reserve account for the month specified by the department. During such period, this payment procedure shall have the same effect as the unrestricted payment of an equal amount to the nursing home company.

(e) After payment of medical bills, a record shall be made:

(1) of the amounts paid to or in behalf of each individual case on the individual record of assistance granted cards maintained for each case; and

(2) of the total transactions in the general accounts maintained by the agency.

(f) Periodically, the sum total of amounts recorded on individual record of assistance granted cards should be reconciled with the control entries in the general accounts. In addition, the public welfare official may require additional records to be kept for administrative purposes.

(g) No payment shall be made for care, services, or supplies for any period of time for which a notification of noncoverability is received from the Commissioner of Health or his designee, or for any period of time for which a notice that services were unnecessary or inappropriate is received from a utilization review committee or a professional standards review organization.

 

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Section 540.9 - Filing of authorizations, bills and related documents.

540.9 Filing of authorizations, bills and related documents. (a) General.

(1) Notifications and authorizations for medical services (either the originals, if available, or copies thereof) shall be maintained on file in the public welfare agency in such a manner as to facilitate audit. If the notification and authorization constitute separate documents, each notification and the authorization relative to it shall be filed together.

(2) Paid bills for medical services shall be maintained on file by the public welfare agency in a manner to facilitate audit and shall be filed in voucher number sequence, or in sequence as listed on the payment rolls.

 

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Section 540.10 - Claims for State aid.

540.10 Claims for State aid. (a) General.

(1) Claims for State (and Federal) aid in behalf of expenditures for medical care shall be prepared and submitted in accordance with departmental regulations with respect thereto.

(2) The internal controls established by the public welfare official for the examination and verification prior to payment of bills for medical services rendered shall identify and isolate any payments or portions of payments that exceed limits stipulated by State regulations and the claims for State (and Federal) aid prepared and submitted by the agency shall exclude from calculations of such aid any such amounts, as required by departmental regulations governing the preparation and submission of claims. Other elements requiring case expenditure analysis entering into the development of proper claims, such as program and residence status, shall also be provided for in the internal analysis and processing of medical services payments.

(3) Where claims and rolls for State aid purposes must be supported by vouchers or statements of services paid for medical care, the public welfare agency must ensure, in its operating procedures, that sufficient copies of the appropriate documents are developed to meet both its internal needs and the roll and claim requirements.

 

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Section 540.11 - Internal administrative safeguards over medical care expendi

540.11 Internal administrative safeguards over medical care expenditures. (a) General. The public welfare official shall establish internal practices that will safeguard the proper expenditure of funds for medical care.

 

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Section 540.12 - Advance payments to hospitals.

540.12 Advance payments to hospitals. (a) Criteria for eligibility. The department is authorized to make advance payments to hospitals which meet the following criteria:

(1) The hospital is a voluntary not-for-profit hospital.

(2) Prior to January 1, 1978, the hospital received regular periodic advances from a local government unit, which advances were based on anticipated medical assistance claims payments.

(3) That, historically, 10 percent or 5,000 patient days of hospital inpatient services must have been provided to Medicaid recipients who reside in a district for which the Medicaid Management Information System (MMIS) has taken over payment responsibility.

(b) Methods of advances. Advance payments of medical assistance funds shall be made to hospitals in the following manner:

(1) Advance payments will be made for the period from June 1, 1978 to November 30, 1978, which period shall be known as the advance phase.

(2) Advance payments will be computed on the basis of a comparison of actual monthly payments for medical assistance to the hospital with the estimated normal monthly payments for medical assistance services. This estimate shall be prepared by the department. The department shall advance funds to account for a percentage of the difference between the actual payments made and the estimated monthly claim at the following rates:

Month Percent June 90% July 80%

August 70%

September 60%

October 50%

November 40%

These rates are subject to the discretion of the commissioner. In no case shall the percentage of monies advanced ever exceed 90 percent of the difference between the estimated claim and total payments received by the hospital.

(3) The only payments to be considered in developing the comparison referred to in paragraph (2) of this subdivision shall be payments for claims submitted to MMIS or to those local social services districts in whose behalf it is operating.

(4) The hospital shall certify as to the amount of inpatient services provided to Medicaid recipients, for which it has not yet billed, in the month for which advance payments are to be received. This certification must be sufficient to account for the entire difference between payments actually received and the estimate developed by the department of the normal month's payment. In the event that such unbilled services are less than this difference, the State will advance only a percentage of the lesser amount.

(5) In the event that at any time during the advance phase, the actual monthly payments to a hospital exceed 100 percent of its estimated normal month's payment, the department may:

(i) withhold from its next monthly advance to that hospital the amount by which the previous month's payment exceeded the estimated normal month's payment; or

(ii) withhold from the regular monthly payment the amount by which the actual payment exceeds the estimated normal month's payment. Monies withheld under this option shall be applied towards the liquidation of any outstanding advances.

(c) Performance criteria. In order for a facility to continue to qualify for advances, it must meet the following performance criteria:

(1) For any month during which an advance is sought, the facility's claim submissions must equal at least 90 percent of its average monthly submissions (trended). Of these, a reasonable percentage will have to pass MMIS edits.

(2) "Clean" claims must be submitted within 15 days of the discharge date in 95 percent of the cases. "Clean" claims are those which do not require submission to other third-party payors, and which do not require eligibility or disability determination.

(3) Where the hospital's claiming pattern clearly indicates that the facility has deliberately withheld claims in order to qualify for the advance, the State may recoup its advance by withholding any payments over 100 percent of the hospital's estimated claiming levels until the amount of the advance is recouped.

(d) Method of recoupment. The department shall recoup all advance payments under the following procedures:

(1) At the close of the last payment cycle of November, each hospital's outstanding advances shall be totalled.

(2) Advances shall be recouped in equal installments over a period of 12 months beginning with the month of December, 1978. The department shall deduct each month from payments made to hospitals participating in this advancing system an amount equal to one twelfth of all advance payments. The recoupment period may be extended to 18 months at the discretion of the commissioner.

(3) Notwithstanding any of the foregoing provisions of this section, the department shall be authorized to modify the schedule of recoupments set out in paragraph (2) of this subdivision upon certification by the State Commissioner of Health of the need for such modification made pursuant to 10 NYCRR 86-1.36 (e); provided, however, that any such modification shall not extend the total period of recoupment beyond 18 months.

(e) Notwithstanding any of the foregoing provisions of this section, the department may, in its discretion, make advances on either a monthly, semimonthly or weekly basis.

 

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Section 540.13 - Concurrent payments to hospitals.

540.13 Concurrent payments to hospitals. (a) To insure timely payment, while providing for transition to a fee for services rendered payment system under the medical assistance program the commissioner shall implement, for a limited period, a concurrent payment system for any eligible nongovernmental general hospital requesting participation to effectuate such transition. Eligible applicants must have:

(1) participated in a limited multi-hospital reimbursement demonstration project; and

(2) been receiving, in lieu of payment for services rendered, fixed weekly payments pursuant to a contractual agreement, during calendar years 1981 and 1982 or their contractual predecessors in a limited multi-hospital reimbursement demonstration project must have; and

(3) more than 25 percent of the patients serviced by the hospital eligible for medical assistance.

(b) Prior to the commencement of payments made pursuant to this section, the commissioner shall submit for approval by the director of the budget a schedule detailing the methodology and specific time period necessary to effectuate transition to a fee for service rendered payment system prior to the end of December 31, 1985.

(c) Payment shall be made biweekly under the concurrent payment system.

(d) The department shall compute the payment amount to equal 1/26 of the hospital's imputed or certified revenue cap, as defined in section 2807-a of the Public Health Law, adjusted for overpayments or underpayments received by the hospital during the concurrent payment period, or a previous period.

(e) Payment shall be made two weeks after the end of each biweekly period.

(f) The department shall review the concurrent payment at the beginning of each quarter and adjust it to reflect any changes by the Department of Health to the inpatient revenue cap or portion allocated for medical assistance payments.

(g) The hospital shall maintain cost, charge and statistical data necessary to accurately complete cost reports on a timely basis, in accordance with standards set by the Department of Social Services and the Department of Health.

(h) Within 15 months after each calendar year, the department shall reconcile the amounts paid pursuant to the concurrent payment system with the amounts of payment that would have been made for services rendered during the calendar year and billed to the department prior to the date of reconciliation. For services provided to Medicaid recipients during the period to be reconciled where such cases are open at the time of reconciliation, payments will be made on a services rendered basis and excluded from reconciled concurrent payment amounts. Nothing shall prohibit the department from performing a reconciliation at any other time as it may determine.

(i) The hospital shall be liable for all overpayments identified pursuant to the reconciliation.

(j) The department may withhold any overpayment, including overpayments arising from the concurrent payment system, from future payments made to the hospital under the medical assistance program.

(k) The hospital must submit its claims in a format acceptable to the Medicaid management information system within the time frame set forth in section 540.6 of this Part.

(l) The department may lower or eliminate the concurrent payment for noncompliance with the provisions of this section.

(m) During any biweekly period prior to May 1, 1983, the department may pay both contractual payments due to the hospital and concurrent payments, but in no event shall the biweekly payment exceed the amount specified in subdivision (d) of this section.

(n) The department shall not make concurrent payment after December 31, 1985.

(o) The department shall adjust concurrent payments to the hospital consistent with the schedule approved by the director of the budget pursuant to subdivision (b) of this section, in order to facilitate transition to a fee for service rendered payment system for such hospital.

(p) This section shall be effective only for so long as Federal financial participation is available for the concurrent payments.

 

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