Part 601 - PROCEDURES OF REIMBURSEMENT CLAIMING

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Statutory Authority: 
Social Services Law, Sections 20, 34, 62, 65, 80, 153

Section 601.1 - Claims for reimbursement.

Section 601.1 Claims for reimbursement. (a) Claims and reports for Federal and State reimbursement and supporting documentation must be prepared in accordance with the directions of the department or, absent such directions, in accordance with the requirements of the relevant Federal agency. The information contained in the claims and supporting documentation will be used by the department in determining whether such claims should be reimbursed.

(b) Except as otherwise directed by the department, claims and supporting documentation must be prepared monthly and submitted to the department at its office in Albany by the 20th of the month following the month to which they relate.

(c) An original statement of claim and supporting documentation must be submitted to the department, and a copy of the claim and documentation must be kept on file by the social services district in a manner to facilitate audit. Any copies required by the fiscal officer of a social services district or other authorities must be supplied by the district.

(d) Claims for reimbursement must be submitted by or through the commissioner of the social services district charged with the administration of the program under which reimbursement is sought. Claims must be certified by the authorized social services official, or his or her deputy, or other official authorized to certify claims for reimbursement, and by the fiscal officer, or his or her deputy, of the municipality or other governmental unit making the claim.

(e) Social services districts must maintain records to supplement their accounts pertaining to indirect expenses included in claims. Such records must reflect the volume of service or supplies provided, the rates at which charges are computed, the total charge for each period covered by a claim and the basis for the rates or charges. The records must be maintained with the same care and protection afforded the operating accounts of the district and must be retained and made readily available for inspection and audit as the department requires.

 

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Section 601.2 - Documentation and summaries.

601.2 Documentation and summaries. (a) Documents and summaries must be established for each activity for which reimbursement is claimed. Such documents and summaries must be established in accordance with the requirements for such activity. Documents must show names of recipients, vendors, providers or other persons or entities to whom payments have been made, the amount of each payment, the character or purpose of the payment and such other pertinent information as may be required by the department. The summary or document must be further supported by such other documents as are required or requested by the department or the State. Such supporting documentation must separately identify the eligibility status of each case covered by the documentation in accordance with procedures established for the particular activity or program for which reimbursement is claimed.

(b) Documents and summaries must be prepared in support of claims for which reimbursement is sought and must be prepared for claims for assistance and care or other reimbursable expenditures made for specific recipients, including but not limited to:

(1) public assistance or other expenditures made in the form of regular or special cash grants to a recipient;

(2) expenditures for payments to vendors, providers or other persons or entities for assistance, care, services or supplies furnished to or on behalf of a recipient; and

(3) adjustments of benefits made to or on behalf of a recipient.

(c) All documents and summaries pertaining to claims for which reimbursement is sought must be maintained by the social services district, together with and in support of claims for State and Federal reimbursement or aid as required by the department.

(d) All documents and summaries which support the specific claim must be kept on file by the social services district in a manner that facilitates the conduct of audits.

 

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Section 601.3 - Reimbursement claiming time limits.

601.3 Reimbursement claiming time limits. Except as otherwise provided, to be eligible for State reimbursement, expenditures for public assistance, care and services, or for any other activity which is subject to reimbursement by the department, must be made within the time limits set forth in this section and must be included in a claim submitted by the social services district to the department for the time period in which such expenditures are claimed to have been made.

(a) Claims for expenditures which are subject to reimbursement by the Federal government or entities other than the department must be submitted to the department in sufficient time so that the department can submit claims to the other claiming sources within the time required by such sources. Claims submitted less than 40 days prior to the time by which the department must submit claims for Federal reimbursement may be considered to be submitted without sufficient time for the department to submit such claims to other claiming sources.

(b) All claims for expenditures for which Federal financial participation is available under the Social Security Act must be submitted to the department so that such claim can be included in any claim submissions by the department to the Secretary of the United States Department of Health and Human Services within the two-year period which begins on the first day of the calendar quarter immediately following the calendar quarter in which such expenditures were made, except with respect to any expenditure involving court-ordered retroactive payments or audit exceptions, or adjustments to prior year costs, unless a waiver for good cause has been made by such Secretary for the particular expenditures submitted.

(c) Except as otherwise provided within the requirements for any particular activity, expenditures made by a social services district may not be reimbursed if such costs are related to expenditures, services, supplies or other costs incurred on behalf of a recipient or an individual more than 12 months prior to the month in which the claim for reimbursement is made, unless such costs are specifically approved by the department.

(d) Claims which are rejected will be reexamined only if resubmitted within six months following the date of rejection, provided (1) the initial submittal was made in accordance with the provisions of subdivision (a) of this section, and (2) the costs or expenditures subject to reimbursement in the resubmitted claim are submitted to the department in sufficient time so that the department can submit such claims to any other claiming source within the time required by such source.

(e) The provisions of this section shall not prevent the department from approving and certifying a claim for State reimbursement when in its judgment the claim has merit and, for good cause, could not have been submitted within the time limits prescribed. The provisions of this subdivision may not be interpreted to require the department to approve such claim.

 

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Section 601.4 - Claim adjudication.

601.4 Claim adjudication. The department will be responsible for examining claims for reimbursement submitted by social services districts. Initial determinations objecting to the allowability of a claim for reimbursement will be made in a timely manner not to exceed 90 days from the time of receipt by the department, unless the department notifies a district that a specified amount of additional time, not to exceed an additional 90 days, is necessary to complete examination of the claim. Any portion of a claim to which there is no initial determination objecting to allowability will be processed for submission for acceptance by a reimbursement authority. Processing will be commenced in a timely manner not to exceed 90 days from the time of receipt of the claim or from the date of an initial determination of allowability. A determination by the department concerning the allowability of a claim for reimbursement submitted by a social services district is final and is not subject to administrative review.

(a) Acceptance or payment by the department of any portion of any claim for such reimbursement does not preclude the department from subsequently examining any portion of such claim and determining that such claim was not subject to reimbursement or should have been reimbursed at a different rate.

(b) Acceptance by the district of reimbursement from the department related to specific reimbursable costs claimed by the district precludes the district from subsequently submitting any additional claims for reimbursement for such costs without the consent of the department.

(c) Acceptance by a social services district of a determination by the department with respect to the allowability of costs or other items purported to be subject to reimbursement on any portion of any claim precludes the district from submitting any additional claims for reimbursement relating to such costs or items without the consent of the department.

(d) Any portion of any costs or other items purported to be subject to reimbursement which are determined to be unacceptable by the department may not be resubmitted for reimbursement or otherwise adjusted without the explicit consent of the department.

(e) The department may request the district to submit, or at the department's option prepare on behalf of the district, a statement of adjustments to any portion of any claim submitted by a district. Any adjustments made by the department to payments or claims for the district constitutes notification of the adjustment when the district receives a copy of the adjustment or has been notified that the adjustment has been made.

(f) Any disallowances, recoupments or adjustments resulting from the action or determination of a Federal or other reimbursement authority must be reflected in adjustments to claims as directed by the department. A copy of any adjustments made by the department constitutes notification to the district of the adjustments when the district receives a copy of the adjustment or is notified that the adjustment has been made. If the determination of the Federal or other reimbursement authority is not final or binding, or if the department has appealed or judicially challenged such determination and the district is so notified, the determination of the department with respect to the district shall not be final and binding until the determination is final and binding upon the department and the district is so notified.

(g) Any adjustments resulting from a post-claim review or audit must be reflected in adjustments to claims as directed by the department. A copy of any adjustments made by the department constitutes notification to the district of the adjustment when the district receives a copy of the adjustment or has been notified that the adjustment has been made.

(h) Any other reductions, recoupments or adjustments must be reflected in adjustments to claims as directed by the department. Such reductions, recoupments or adjustments when made by the department are final and binding when the district is notified that the reduction, recoupment or adjustment has been or will be made.

 

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Section 601.5 - Claim audits.

601.5 Claim audits. At least one copy or comparable record of each of the documents necessary to comply with the claiming requirements of this Part, including the submitted claim, and one copy or comparable record of the payroll, must be retained by the local district to facilitate audits conducted by the department or its designees. The district must furnish copies of such records to the department, other State agencies, a local fiscal officer or other governmental entity when so directed by the department.

(a) Except as otherwise directed by the department or required by law, records must be kept in a manner available for review and audit for a period of at least six years.

(b) The district must cooperate in any audit or review conducted by or with the approval of the department.

(c) The department must be notified in writing within five working days after receipt of any request or notice that the district participate in any audit not specifically requested or approved by the department.

(d) Any adjustment required by or resulting from any audit or review must be reflected in adjustments to claims as directed by the department.

(e) Audit determinations by the department are final and not subject to administrative review, except as otherwise provided by paragraph (e) of subdivision (2) of section 22 of the Social Services Law, when reflected in adjustments to claims of a social services district by direction of the department or when the district is otherwise notified that the determination is final.

(f) Adjustments resulting from an audit or review conducted by an entity other than the department are subject to review and audit by the department.

(g) Except as otherwise required by law, the department may prescribe or direct any or all procedures or requirements that the district must follow with respect to any audits, reviews or fiscal investigations.

 

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