Section 513.7 - Determinations.

513.7 Determinations. (a) The Department of Health must issue a written determination approving, modifying or denying a request within the time periods provided under section 85.37 of the Department of Health regulations (10 NYCRR). If the determination modifies, or denies a request, either in whole or in part, the written determination must set forth the general nature of the request; the relevant facts; the applicable guidelines, rules, regulations, and medical standards; and the reasons for modifying or denying the request. However, if supporting factual, medical, or other information is requested from the recipient, or the ordering or treating practitioner or potential provider, or if a clinical examination is required, the time to issue a determination is extended as provided in section 85.37 of the Department of Health regulations (10 NYCRR).

(b) The determination must be based upon a professional review by Department of Health personnel of clinical information and opinion; factual, medical, and other relevant information submitted to, or obtained by, the Department of Health; the written guidelines of the Department of Health; the regulations of this department; and commonly accepted medical practice.

(c) A copy of the written determination denying or modifying the request, including a formal notice of hearing rights which meets the requirements of Part 358 of this Title, must be sent to the recipient within the time period specified in subdivision (a) of this section.

(d) If the requested medical, dental and remedial care, services or supplies are otherwise available under the MA program and there is no clinical information or documentation conflicting with the opinion of the ordering or treating practitioner, the Department of Health must approve the request as submitted.

(e) If the recipient does not appear for a clinical examination as required by the Department of Health, or in accordance with prior alternative arrangements made with the recipient, the Department of Health may deny the request.

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