Section 515.1 - Scope and definitions.

Section 515.1 Scope and definitions. (a) Scope. This Part sets forth the requirements and procedures for:

(1) sanctioning persons under the medical assistance program;

(2) recovering overpayments resulting from unacceptable practices;

(3) obtaining restitution;

(4) administrative appeals of sanctions and overpayments; and

(5) reinstatement into the medical assistance program.

(b) Definitions. The terms defined in Part 504 of this Title have the same meanings for purposes of this Part. In addition, for purposes of this Part, 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 medical assistance program, payments for services which were not medically necessary, or payments for services which fail to meet recognized standards for health care.

(2) Censure means a warning that continued conduct of the type or nature cited may result in a more severe sanction. A censure may serve as a basis for imposition of a more severe sanction against the same person or an affiliate on a subsequent matter, whether or not the subsequent matter is related to the matter for which a censure was issued.

(3) Claim means any request for payment under the medical assistance program. Where a claim form, voucher or invoice contains more than one item of care, services or supplies, each item will be considered a separate claim.

(4) Commissioner means the State Commissioner of Social Services, or any person designated to represent the commissioner.

(5) Department means the State Department of Social Services.

(6) Exclusion means that items of medical care, services or supplies furnished by the provider or ordered or prescribed by the provider will not be reimbursed under the medical assistance program.

(7) Fraud means an intentional deception or misrepresentation made with the knowledge that the deception could result in an unauthorized benefit to the provider or another person and includes the acts prohibited by section 366-b of the Social Services Law.

(8) Furnish means that medical care, services or supplies are provided directly by, or under the supervision of, or ordered or prescribed by the person.

(9) Program means the medical assistance program.

(10) Sanction means any final administrative action taken by the department under this Part which limits a person's participation in the medical assistance program. Sanctions which may be imposed are set forth in section 515.3 of this Part.

 

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