LIMITATION ON HOSPITAL STAY

Section 85.5 - Limitation on hospital stay

LIMITATION ON HOSPITAL STAY

85.5 Limitation on hospital stay.

(a) To be a covered benefit under medical assistance for the needy as provided in section 365-a(2)(b) of the Social Services Law, any hospital stay beyond 20 days per spell of illness, except for rehabilitation care as hereinafter provided, during which all or any part of the cost of such care, services and supplies are claimed as items of medical assistance shall require a prior determination of coverability by a person designated by the Commissioner of Health. Any hospital stay for care under an established plan for rehabilitation of physical disability in a rehabilitation hospital or rehabilitation unit, beyond 40 days shall require such prior determination of coverability. A written request for such determination shall be made by the patient's physician. Such request shall include evidence documented in the patient's medical record showing that in order to preserve life or to prevent substantial risk of continuing disability, an additional period of care is required of such complexity or intensity that it can be provided only in a hospital. Care of such complexity or intensity shall include, but not be limited to:

(1) severe burns requiring continued therapy in a burns unit.

(2) continuing cardiovascular, renal or pulmonary decompensation requiring care in a coronary care unit, intensive care unit, pulmonary care unit or other acute care setting in the hospital.

(3) central nervous system damage with threatened or impaired consciousness.

(4) persistent fever or serious infection.

(5) persistent hemorrhage or threat of recurrent hemorrhage.

(6) life threatening conditions including malignancy when chemotherapy, radiotherapy or other therapy can be provided and monitored effectively only in a hospital.

(7) conditions requiring physical rehabilitation under an established rehabilitation plan when such treatment can be carried out only in a hospital setting.

(b) Such request for determination of coverability for continued care shall be made before the 20th but not before the 16th day of stay. The determination of coverability shall be for an additional period not to exceed 10 days after the 20th day of stay. Determination of coverability shall be made for additional periods of stay not to exceed 10 days each pursuant to written requests submitted as aforesaid prior to expiration of the last period for which there has been a determination of coverability.

(c) In the case of care under an established plan for rehabilitation of physical disability referred to in subdivision (a) of this section, the request for extended coverability determination shall be made before the 40th but not before the 36th day of stay, and determination of coverability shall not exceed 20 days for the initial additional period of stay and for any additional period thereafter.

(d) Spell of illness, for the purpose of this section, shall begin on the first day of hospital care and shall end 60 days following discharge from the hospital inpatient service. Except in case of emergency or urgency, readmission during said 60 day period shall be subject to the prior approval of the commissioner's designee upon a showing of necessity to preserve life or to prevent substantial risk of disability.

(e) A determination of coverability may be granted by a designated physician or non-physician under the supervision of a physician. A determination of noncoverability shall be made only by a designated physician. Notice of determination shall be given to the patient's physician, the hospital administrator, and if there is a determination of noncoverability to the patient. A written record of determinations made of such coverability or noncoverability shall be entered in the hospital records and made available for review.

(f) The patient's physician or hospital administrator may, within three days of the date of such notification, appeal such determination of noncoverability in writing to the physician or physicians designated by the Commissioner of Health for such purpose. Notification of decision on appeal shall be given to the patient's physician, the hospital administrator and the patient. If there is a determination of noncoverability or such determination of noncoverability is affirmed on appeal, any inpatient hospital care, services or supplies provided during the additional period of stay requested shall not be a covered benefit under medical assistance for the needy.
 

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Section 85.6 - Admissions and hospital stays

85.6 Admissions and hospital stays.

(a) Inpatient hospital admissions which do not require a determination of benefit coverability under sections 85.1 through 85.4 of this Part and except for admissions under subdivision (f) of this section shall be deemed a covered benefit under medical assistance for the needy as provided in section 365-a(2)(b) of the Social Services Law for the first three days of inpatient hospital care. To be a covered benefit after the third day of inpatient hospital care, there shall be a determination of benefit coverability prior to the end of the third day by a person designated by the Commissioner of Health. Such determination shall be for a specified period of time not to exceed the 50th percentile of length of stay norms for comparable patients which have been authorized by the Commissioner of Health or the 20th day of stay, whichever is less. If the stay is for rehabilitation of physical disability as described in subdivision (a) of section 85.5 of this Part, such specified period of time shall not exceed the 40th day of stay. Determination of coverability shall be based upon existence of medical conditions which can be treated only on an inpatient hospital basis, as documented in the patient's medical record. Subsequent to this initial determination of coverability, extensions of benefit coverability shall be subject to length of stay limitations of sections 85.5 and 85.7 of this Part.

(b) A determination of benefit coverability under this section shall be made by a designated physician or nonphysician under a designated physician's supervision. A determination of noncoverability shall be made only by a designated physician. If such determination of noncoverability is made, any inpatient hospital care, supplies or services provided beyond three days shall not be a covered benefit under medical assistance for the needy.

(c) Notice of determination shall be given to the patient's physician, the hospital administrator and, if there is a determination of noncoverability, to the patient.

(d) The patient's physician or hospital administrator may, within three days of the date of such notification, appeal a determination of noncoverability in writing to the physician or physicians designated by the commissioner for such purpose. Notification of the decision on appeal shall be given to the patient's physician, the hospital administrator and the patient. If determination of noncoverability is affirmed on appeal, any inpatient hospital care, supplies or services provided beyond three days shall not be a covered benefit under medical assistance for the needy.

(e) If the person designated by the Commissioner of Health decides in the course of making determinations of coverability under this section or it is determined from other sources that a physician, physicians or the hospital are admitting patients for medical conditions which can be treated on other than an inpatient hospital basis, the designated person shall give written notification to the physician(s) and the hospital that if such admissions continue, the initial three-day period of stay will no longer be deemed a covered benefit. If patients are thereafter admitted for medical conditions which can be treated on other than an inpatient hospital basis, the designated person shall notify the physician(s) and the hospital that to be a covered benefit, the first three days of inpatient stay will be subject to a determination of coverability. Such determination of coverability shall be made prior to the end of the third day of inpatient hospital stay in accordance with the procedures in subdivisions (a) through (d) of this section. If there is a determination of noncoverability, any inpatient hospital care, supplies or services provided shall not be a covered benefit under medical assistance for the needy.
(f)(1) During such period of time as sections 85.2 and 85.3 of this Part do not apply, all surgery, other than emergency or urgent surgery, within "medical assistance" as defined in section 365-a of the Social Services Law, shall require a determination of coverability by a person designated by the Commissioner of Health prior to admission. A determination of coverability shall be based on a finding that the proposed surgery can be performed properly only on an inpatient hospital basis.
(2) A determination of coverability shall be for a specified period of time not to exceed the 50th percentile of length of stay norms for comparable patients which have been authorized by the commissioner or the 20th day of stay, whichever is less. If the stay is for rehabilitation of physical disability as described in section 85.5(a) of this Part, such specified period of time shall not exceed the 40th day of stay. Subsequent to this initial determination of coverability, extensions of benefit coverability shall be subject to length of stay limitations of sections 85.5 and 85.7 of this Part. (3) The required determination of coverability shall be initiated by written request from the proposing surgeon, with information adequate for making the determination. A determination of coverability shall be made by a designated physician or nonphysician under supervision of a designated physician. A determination of noncoverability shall be made only by a physician.
(4) Notice of determination shall be given to the proposing surgeon who shall, if coverability is determined, incorporate such notice in the hospital record at admission.
(5) The proposing surgeon may appeal any determination of noncoverability to a physician or physicians designated by the Commissioner of Health for such purpose. Notification of decision on appeal shall be given to the proposing surgeon who shall incorporate any notice of determination of coverability in the hospital record at admission.
(6) Admissions and hospital stays solely for the purpose of performing any procedure which may be performed on an outpatient basis, as defined in paragraph (7) of this subdivision, shall not be included as inpatient care in a hospital or care in a hospital-based ambulatory surgery service or a free-standing ambulatory surgery center for purposes of coverability of benefits except that a determination of coverability may be made by a person designated by the Commissioner of Health when the medical condition of the individual patient requires that such procedure be performed on an inpatient basis in a hospital or as care in a hospital-based ambulatory surgery service or a free-standing ambulatory surgery center. For inpatient hospital, hospital-based ambulatory surgery service and free-standing ambulatory surgery center admissions for certain surgical procedures, as defined in paragraph (7) of this subdivision there shall be a determination prior to admission of the specified period of coverability as provided for in this subdivision, except for emergency admissions for which the determination of the period of coverability shall be made as soon after admission as feasible.
(7) A procedure which may be performed on an outpatient basis ("outpatient procedure"), is a diagnostic test or treatment, including certain surgical procedures, that carries a low patient risk, requires minimal pre- and post-procedure observation and treatment, is not likely to be time consuming or followed by complications, and is not associated with a condition which would require hospitalization. Column (1) lists "The International Classification of Diseases, 9th Revision, Clinical Modification" (ICD-9-CM) procedure codes for outpatient surgery and column (2) below lists the outpatient surgical (ICD-9-CM) procedure names. Such outpatient procedures include, but are not limited to, the following:
(1) (2)
ICD-9-CM Procedure Code ICD-9-CM Procedure Name
(i) 3.31 Spinal tap (ii) 8.09 Other eylid incision (iii) 8.11 Eyelid biopsy (iv) 8.20 Removal of lesion of eyelid, NOS (v) 8.21 Excision of chalazion (vi) 8.22 Excision of other minor lesion of eyelid (vii) 8.41 Repair entrop/ectro-thermocauterization (viii) 8.42 Repair entrop/ectro. by suture tech. (ix) 8.52 Blepharorrhaphy (x) 18.09 Other incision of external ear (xi) 18.21 Excision of preauricular sinus (xii) 18.29 Excis./destruct. of other lesion ext. ear (xiii) 20.09 Other myringotomy (xiv) 21.21 Rhinoscopy (xv) 21.22 Biopsy of the nose (xvi) 21.30 Excis./destruct. of lesion-nose, NOS (xvii) 21.31 Local excsn./destruct.-intranasal lesion (xviii) 21.32 Local excsn./destruct.-other lesion of nose (xix) 21.61 Turbinectomy by diathermy or cryosur (xx) 21.69 Other Turbinectomy (xxi) 23.01 Forceps extraction of deciduous tooth (xxii) 23.09 Forceps extraction of other tooth (xxiii) 23.11 Surgical removal of residual root (xxiv) 23.19 Other surgical extraction of tooth (xxv) 23.20 Restoration of tooth by filling (xxvi) 23.30 Restoration of tooth by inlay (xxvii) 23.41 Application of crown (xxviii) 23.42 Insertion of fixed bridge (xxix) 23.43 Insertion of removable bridge (xxx) 23.49 Other dental restoration (xxxi) 23.50 Implantation of tooth (xxxii) 23.60 Prosthetic dental implant (xxxiii) 23.70 Root canal, NOS (xxxiv) 23.71 Root canal therapy with irrigation (xxxv) 23.72 Root canal therapy with apicoectomy (xxxvi) 23.73 Apicoectomy (xxxvii) 24.00 Incision of gum or alveolar bone (xxxviii) 24.11 Biopsy of gum (xxxix) 24.12 Biopsy of alveolus (xl) 24.19 Other diag. proc. on teeth, gums (xli) 24.20 Gingivoplasty (xlii) 24.31 Excison of lesion of tissue of gum (xliii) 24.32 Suture of laceration of gum (xliv) 24.39 Other operations on gum (xlv) 24.40 Excision of dental lesion of jaw (xlvi) 24.50 Alveoloplasty (xlvii) 24.60 Exposure of tooth (xlviii) 24.70 Application of orthodontic appliance (xlix) 24.80 Other orthodontic operation (l) 24.91 Extension or deepening of buc. sulcus (li) 24.99 Other dental operations (lii) 25.02 Open biopsy of tongue wedge biopsy (liii) 25.10 Excisn./destuctn lesion/tissue tongue (liv) 27.43 Other excision of lesion/tissue lip (lv) 27.49 Other excision of mouth (lvi) 27.59 Other plastic repair of mouth (lvii) 31.42 Laryngoscopy and other tracheoscopy (lviii) 45.24 Flexible sigmoidoscopy (lix) 48.23 Rigid Proctosigmoidoscopy (lx) 48.25 Open biopsy of rectum (lxi) 49.23 Anal biopsy (lxii) 49.30 Loc. excsn./dest. oth. lesion/tissue of anus (lxiii) 49.45 Hemorrhoid ligation (lxiv) 49.47 Evacuation of thrombosed hemorrhoid (lxv) 56.91 Ureteral meatus dilation (lxvi) 57.19 Other cystostomy (lxvii) 57.32 Other cystoscopy (lxviii) 57.33 Closed (transur) biopsy of bladder (lxix) 57.94 Insertion of indwelling urinary cath (lxx) 57.95 Replacement-indwelling urinary cath (lxxi) 58.10 Urethral meatotomy (lxxii) 59.80 Urethral catheterization (lxxiii) 83.21 Biopsy of soft tissue (lxxiv) 86.04 Other incsn w/drainage of skin/ subcu. tissue (lxxv) 86.11 Biopsy of skin & subcutaneous tissue (lxxvi) 86.22 Excision debrid of wound infection or burn (lxxvii) 86.23 Removal of nail, nailbed, nail fold (lxxviii) 86.25 Dermabrasion (lxxix) 86.59 Suture skin/subcut. tissue of other sites (lxxx) 88.66 Phlebography - femoral, other lower extrm vein material (lxxxi) 89.26 Gynecological examination (lxxxii) 97.71 Remove intrauterine contraceptive device (8) Admissions and hospital stays solely for the purpose of performing any procedure which may be performed on an ambulatory surgery basis as defined in paragraph (9) of this subdivision, shall not be included as inpatient care in a hospital for purposes of coverability of benefits except that a determination of coverability may be made by a person designated by the Commissioner of Health when the medical condition of the individual patient requires that such procedure be performed on an inpatient basis in a hospital. For inpatient hospital admissions for procedures listed in paragraph (9) of this subdivision, there shall be a determination prior to admission of the specified period of coverability as provided for in this subdivision, except for emergency admissions for which the determination of the period of coverability shall be made as soon after admission as feasible.
(9) A procedure which may be performed on an ambulatory surgery basis ("ambulatory surgery procedure"), is a diagnostic test, treatment, or procedure which shall be performed for safety reasons in an operating room on anesthetized patients requiring a stay of less than 24 hours' duration. These procedures do not include outpatient office or outpatient treatment room procedures as defined in and covered by paragraph (7) of this subdivision. Column (1) below lists the "The International Classification of Diseases, 9th Revision, Clinical Modification" (ICD-9-CM) procedure names for ambulatory surgical procedures and Column (2) lists the ICD-9-CM procedure codes for ambulatory surgical procedures for which prior approval is necessary for inpatient hospital admission, except for emergency admissions for which the determination of the period of coverability shall be made as soon after admission as feasible. Such ambulatory surgery procedures include, but are not limited to the following:
(1) (2)
ICD-9-CM Procedure Named ICD-9-CM Procedure Codes
(i) spinal tap 03.31
(ii) other excision or avulsion of cranial and peripheral nerves 04.07
(iii) release of carpal tunnel 04.43
(iv) other peripheral nerve or ganglion decompression or lysis of adhesion 04.49
(v) excision of pterygium 11.39
(vi) intracapsular extraction of lens by temporal inferior route 13.11
(vii) other intracapsular extraction of lens 13.19
(viii) extracapsular extraction of lens by simple aspiration (and irrig.) technique 13.3
(ix) extracapsular extraction of lens by temporal inferior route 13.51
(x) other extracapsular extraction of lens 13.59
(xi) insertion of pseudophakos, NOS 13.70
(xii) insertion of intraocular lens prosthesis at cataract extraction, 1-stage 13.71
(xiii) secondary insertion of intraocular lens prosthesis 13.72
(xiv) recession of one extraocular muscle 15.11
(xv) advancement of one extraocular muscle 15.12
(xvi) resection of one extraocular muscle 15.13
(xvii) other operation on one extraocular muscle involving temporary detachment from globe 15.19
(xviii) lengthening procedure on one extraocular muscle 15.21
(xvix) shortening procedure on one extraocular muscle 15.22
(xx) other operations on one extraocular muscle 15.29
(xxi) operations on two or more extraocular muscles involving temporary detachment from globe, one or both eyes 15.3
(xxii) excision or destruction of other lesion of ext. ear 18.29
(xxiii) myringotomy with insertion of tube 20.01
(xxiv) other myringotomy 20.09
(xxv) submucous resection of nasal septem 21.5
(xxvi) closed reduction of nasal fracture 21.71
(xxvii) revision rhinoplasty 21.84
(xxviii) other rhinoplasty 21.87
(xxix) other septoplasty 21.88
(xxx) other excision or destruction of lesion or tissue of larynx 30.09
(xxxi) laryngoscopy and other tracheoscopy 31.42
(xxxii) biopsy of larynx 31.43
(xxxiii) bronchoscopy through artificial stoma 33.21
(xxxiv) fiber-optic bronchoscopy 33.22
(xxxv) other bronchoscopy 33.23
(xxxvi) biopsy of lymphatic structure 40.11
(xxxvii) simple excision of other lymphatic structure 40.29
(xxxviii) biopsy of bone marrow 41.31
(xxxix) esophagoscopy through artificial stoma 42.22
(xl) other esophagoscopy 42.23
(xli) biopsy of esophagus 42.24
(xlii) gastroscopy through artificial stoma 44.12
(xliii) other gastroscopy 44.13
(xliv) other endoscopy of small intestine 45.13
(xlv) flexible fiberoptic colonoscopy 45.23
(xlvi) other endoscopy of large intestine 45.24
(xlvii) local excision of rectal lesion or tissue 48.35
(xlviii) incision or excision of perianal tissue 49.01
(xlix) local excision or destruction of other lesion or tissue of anus 49.3 (l) other procedures on hemorrhoids 49.49
(li) laparoscopy 54.21
(lii) other cystoscopy 57.32
(liii) urethral meatotomy 58.1
(liv) release of urethral stricture 58.5
(lv) dilation of urethra 58.6
(lvi) bilateral endoscopic ligation and crushing of fallopian tubes 66.21
(lvii) bilateral endoscopic ligation and division of fallopian tubes 66.22
(lviii) other bilateral endoscopic destruction or occulsion of fallopian tubes 66.29
(lix) other cervical biopsy 67.12
(lx) dilation and curettage for termination of pregnancy 69.01
(lxi) other dilation and curettage 69.09
(lxii) aspiration curettage of uterus for termination of pregnancy 69.51
(lxiii) other aspiration curettage of uterus 69.59
(lxiv) marsupialization of Bartholin's gland (cyst) 71.23
(lxv) other bunionectomy 77.59
(lxvi) removal of internal fixation device 78.6
(lxvii) arthroscopy (knee) 80.26
(lxviii) excision of lesion of tendon sheath of hand 82.21
(lxix) excision of lesion of other soft tissue 83.39
(lxx) other biopsy of breast 85.12
(lxxi) local excision of lesion of breast 85.21
(lxxii) incision w/removal of foreign body from skin and subcutaneous tissue 86.05
(lxxiii) application of other cast 93.53
(10) Nothing contained in either paragraph (8) or (9) of this subdivision shall prevent any of the procedures listed in, or otherwise covered by, paragraph (9) of this subdivision from being performed on an outpatient basis.
(g) Inpatient hospital care, services and supplies for admissions beginning on a Friday or Saturday shall include as a covered benefit under medical assistance for the needy only those inpatient days beginning with and following the Sunday after such admission unless a person designated by the Commissioner of Health makes a determination of coverability for such Friday or Saturday while making the determinations required in subdivision (a) of this section and section 85.7 of this Part. A determination of coverability shall be based upon a finding that:
(1) such care, services and supplies commencing with a Friday or Saturday admission are furnished for a medical emergency;
(2) such care, services and supplies commencing with a Friday or Saturday admission are required because of the necessity of emergency or urgent surgery for the alleviation of severe pain or the necessity for immediate diagnosis or treatment of conditions which threaten disability or death if not promptly diagnosed or treated; or
(3) the care, services and supplies commencing with a Friday or Saturday admission are for preoperative care for surgery which has been determined to be a covered benefit under section 85.4 of this Part.
(h) Inpatient days beginning on a Friday or Saturday shall not be subject to the limitations of subdivision (g) of this section in hospitals determined by the commissioner or his designee to be rendering full service on a seven-day-a-week basis. A determination of "full service" shall be made after taking into consideration such factors as the routine availability and use of operating room services, diagnostic services and consultants, laboratory services, radiological services, pharmacy services, staff patterns consistent with full services and such other factors as the commissioner or his designee deems necessary and appropriate.
(i) A determination of coverability of admissions to general hospitals for psychiatric care for persons 16 years of age and older requires that the following shall be met:
(1) The patient's hospital medical record shall contain one or more of the following as documentation for the necessity for admission:
(i) evidence of behavior or thought by the patient, described in the patient's medical record, that is likely to lead to consequences which are a significant danger to the patient or others;
(ii) evidence of deviant behavior exhibited by the patient and described in the patient's medical record, which is no longer tolerable to the patient or to society and is likely to be ameliorated by treatment at this level of care;
(iii) the finding that ambulatory treatment has been unsuccessful in halting or reversing the course of the mental illness, and that inpatient treatment at this level of care is needed in order to prevent or manage behavior or thought described in subparagraph (i) or (ii) of this paragraph;
(iv) the finding that the patient requires a type of therapy which cannot be initiated or continued unless in a supervised setting at this level of care; or
(v) the finding that the patient has a condition other than mental disorder which requires hospital care, but psychological components cannot be handled as well on other units.
(2) A specific treatment plan shall be developed and shall have been implemented within three days following admission. (3) The patient's response to treatment must be observed and shall be recorded in the patient's medical record.
(4) An anticipated discharge plan shall be developed by the medical staff and shall be recorded in the patient's medical record no later than the fifth day following admission.
(5) A review of the necessity for continued stay shall be carried out in accordance with the provisions of subdivision (b) of section 85.5 of this Part. The patient's hospital medical record shall contain one or more of the following as documentation for the necessity for continued hospital stay:
(i) evidence that there is an immediate physical danger to the patient or others and this level of care is appropriate;
(ii) evidence that the magnitude of the abnormal behavior of the patient remains intolerable to the patient or society, and clinical evidence recorded in the medical chart justifies an extension of stay at this level of care under treatment;
(iii) a finding that if the patient were to be discharged, subparagraph (i) or (ii) of this paragraph; would be likely to recur soon and continued hospitalization would be likely to prevent this. The medical record must document the reason why it is believed likely to recur soon and why continued hospitalization would be likely to prevent the recurrence;
(iv) a finding that the patient's care requires the use and regulation of a specific modality, but the patient lacks motivation and refuses, or is unable, to cooperate under a program of care at another level;
(v) evidence suggests that the patient can improve sufficiently to be treated in an ambulatory setting or other level of care only after additional hospitalization because a major revision of treatment plan has occurred such as (a) change in treatment regimen or (b) patient relapsed unexpectedly; or
(vi) a condition other than mental disorder requires this level of care, but psychological component cannot be handled as well on other services.

Effective Date: 
Wednesday, January 27, 1993
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Section 85.7 - Extension of hospital stay

85.7 Extension of hospital stay.

(a) To be a covered benefit under medical assistance for the needy as provided in section 365-a(2)(b) of the Social Services Law, any inpatient stay which exceeds the period of time determined to be a covered benefit under sections 85.1 through 85.6 of this Part and under this section but does not exceed a total of 20 days or, if for rehabilitation of physical disability as described in subdivision (a) of section 85.5 of this Part, a total of 40 days, shall be subject to a determination of extended coverability. Such determination shall be made by a person designated by the Commissioner of Health, shall be made prior to the expiration of the previously determined period of covered benefit and shall be for a specified period of time not to exceed applicable length of stay norms for comparable patients which have been authorized by the Commissioner of Health or the 20th day of stay, whichever is less. If the stay is for rehabilitation of physical disability as described in subdivision (a) of section 85.5 of this Part, such specified period of time shall not exceed the 40th day of stay. Determination of extended coverability shall be based upon existence of medical conditions which can be treated only by continued care on an inpatient hospital basis as documented in the patient's medical record.

(b) While making a determination of coverability, if the person designated by the Commissioner of Health determines that during a previously determined period of covered benefit, the care, supplies and services actually provided did not require provision on an inpatient hospital basis, the designated person may make a determination of noncoverability as to part or all of such previously determined period of covered benefit under medical assistance for the needy.

(c) A determination of benefit coverability under this section shall be made by a designated physician or nonphysician under a designated physician's supervision. A determination of noncoverability shall be made only by a designated physician. If such determination of noncoverability is made, any inpatient hospital care, supplies or services provided beyond the previously determined period of covered benefit shall not be a covered benefit under medical assistance for the needy.

(d) Notice of determination shall be given to the patient's physician, the hospital administrator and, if there is a determination of noncoverability, to the patient.

(e) The patient's physician or hospital administrator may, within three days of the date of such notification, appeal a determination on noncoverability in writing to the physician or physicians designated by the commissioner for such purpose. Notification of the decision on appeal shall be given to the patient's physician, the hospital administrator and the patient. If the determination of noncoverability is affirmed on appeal, any inpatient hospital care, supplies, or services provided beyond the previously determined period of covered benefit shall not be a covered benefit under medical assistance for the needy.

(f) Any hospital care, services or supplies covered as a benefit under this section shall be subject to length of stay limitations of section 85.5 of this Part.
 

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Section 85.8 - Alternate level of care placement

85.8 Alternate level of care placement.

(a) During the process of making determinations of coverability as specified in sections 85.1 through 85.7 of this Part, if the person designated by the Commissioner of Health decides that the patient may require placement in an alternate level of medical care upon discharge from the hospital, the designated person shall refer such case to the discharge planning unit of the hospital for appropriate placement action.

(b) During the process of making determination of coverability under sections 85.1 through 85.7 of this Part, if the person designated by the Commissioner of Health determines that the patient no longer requires inpatient hospital care but cannot be discharged except to a lesser level of medical care, he shall make a determination of noncoverability unless the hospital demonstrates that it has made and is continuing to make every effort to place the patient but without success.

(c) For all patients for whom reimbursement is claimed under medical assistance for the needy who require placement in a nursing home or health-related facility at time of discharge from a hospital, patient review forms as required by the State Department of Health must be completed by the hospital as follows:

(1) (i) The Hospital/Community Patient Review Instrument (Hospital/Community PRI), as contained in section 400.13 of this Title, shall be completed by a registered professional nurse who has successfully completed a training program in patient case mix assessment approved by the department to train individuals in the completion of the Patient Review form (PRI) or the Hospital/Community Patient Review form (Hospital/Community PRI). The SCREEN as contained in section 400.12 of this Title shall be completed by a professional with demonstrated skills in assessing psychosocial situations, including but not limited to social work and discharge planning professionals, who has successfully completed a training program in patient case mix screening approved by the department to train individuals in the completion of the patient screening form (SCREEN); or

(ii) each hospital shall have on staff one trained and qualified assessor, and one trained and qualified screener, each as described in subparagraph (i) of this paragraph, for every 70 medical surgical beds, who shall attest to the accuracy of the patient review forms, except that no more than nine trained and qualified assessors and nine trained and qualified screeners shall be required in a hospital.

(2) The Hospital/Community PRI, as contained in section 400.13 of this Title, shall have been completed prior to or within 24 hours of the patient's assignment to alternate level of care (ALC) status, and every 15 days for the first 30 days, and every 30 days thereafter, and within 24 hours prior to the time of discharge to a skilled nursing facility or a health-related facility, unless a different schedule is contained in 18 NYCRR 505.20.

(3) The SCREEN, as contained in section 400.12 of this Title, shall have been completed prior to or within 24 hours of the patient's assignment to ALC status, and every 30 days thereafter, unless a different schedule is contained in 18 NYCRR 505.20.

(4) The Hospital/Community PRI and SCREEN, as contained in sections 400.12 and 400.13 of this Title, shall also be completed when the patient's status changes, as evidenced by a change in the patient's assigned Resource Utilization Group (RUG-II). (See Appendix 13-A, infra, for RUG-II categories.) (5) The patient and/or the patient's designated representative shall be given an explanation of the information contained on the SCREEN, including the determination of setting for care for that particular patient.

(6) Patients younger than 16 years of age shall be assessed at the frequency specified in paragraph (2) of this subdivision, using patient review forms as required by the facility(ies) to which the patient is referred for care upon discharge.
 

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Section 85.9 - Responsibilities of persons designated by the Commissioner of Health

85.9 Responsibilities of persons designated by the Commissioner of Health.

Persons designated by the Commissioner of Health as specified under sections 85.1 through 85.8 and section 85.13 of this Part shall complete and forward reports of their activities as specified by the Commissioner of Health. The designated persons shall maintain copies of all notices of determinations of coverability and noncoverability and notifications of decisions on appeal and records which document the basis for all determinations of coverability and noncoverability and decisions on appeal and shall make such copies and records available to persons designated by the Commissioner of Health for review and evaluation as required.
 

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Section 85.10 - Responsibilities of hospitals

85.10 Responsibilities of hospitals.

(a) In addition to their responsibilities specified under other sections of this Part, hospitals shall provide such information, facilities and services as requested by the persons designated by the Commissioner of Health to make determinations of coverability or decisions on appeal under sections 85.1 through 85.9 and section 85.13 of this Part.

(b) Hospitals shall designate an employee of the hospital to serve as liaison with the persons designated by the Commissioner of Health to make determinations of coverability or noncoverability or decisions on appeal under sections 85.1 through 85.9 and section 85.13 of this Part.

(c) Hospitals shall maintain copies of all notices of determinations of benefit coverability and noncoverability and notifications of decisions on appeal made by the commissioner's designees under this Part and given to the hospital. The hospital shall make such copies available for review by persons designated by the Commissioner of Health, the State Department of Social Services or local social services districts.

(d) Hospitals shall record on each claim for reimbursement under medical assistance for the needy for inpatient hospital care the period or periods of time approved as covered benefits by the commissioner's designee under this Part and shall certify on each claim that reimbursement is being requested only for inpatient hospital care determined to be a covered benefit by the commissioner's designee or that a determination is not required under this Part.
 

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Section 85.11 - Determinations of Commissioner of Health

85.11 Determinations of Commissioner of Health.

(a) The Commissioner of Health may make a determination, as appropriate, that part or all of past, present or future inpatient care, services and supplies in a hospital are not a covered benefit under medical assistance for the needy if the hospital:

(1) has failed adequately to review, act upon, and report to the department regarding discharge information provided to the hospital which has been compiled and analyzed by the department from information submitted to it by the hospital under paragraph (4) of subdivision (e) of section 405.3, Medical Facilities - Minimum Standards;

(2) has failed to correct the deficiencies identified by the review of such discharge information;

(3) has failed to submit discharge information on the forms required under paragraph (4) of subdivision (e) of section 405.9, Medical Facilities - Minimum Standards or subdivision (c) of section 85.8 of this Part or has provided information on such forms which is not complete or not accurate.

(4) has claimed reimbursement for patients who did not meet benefit coverability definitions under this Part during a portion of or all of their inpatient hospital stay.

(5) has provided care, services and supplies in a manner which results in excessive patient stay;

(6) has failed fully to record information justifying benefit coverability of care or services provided;

(7) has failed to comply with section 405.26, Medical Facilities - Minimum Standards pertaining to utilization review;

(8) has failed to fulfill its responsibilities under this Part.

(b) Such determinations of noncoverability may be made with respect to inpatient hospital care which the commissioner's designee has previously determined to be a covered benefit under medical assistance for the needy. No determination of noncoverability shall be made pursuant to paragraphs (4), (5) and (6) of subdivision (a) of this section if the commissioner's designee has previously determined such inpatient hospital care to be a covered benefit under medical assistance for the needy and the designee was an employee of the State Department of Health.

(c) The commissioner may make a determination that certain conditions and types of inpatient hospital care, services and supplies are not a covered benefit as inpatient hospital care under medical assistance for the needy when evaluation and study of such conditions and types of care, services and supplies results in a finding that such care, services and supplies are not required to be performed on an inpatient hospital basis.
 

Effective Date: 
Friday, March 24, 1989
Doc Status: 
Complete

Section 85.12 - Other remedies

85.12 Other remedies.

The remedies provided in sections 85.1 through 85.11 of this Part shall not be exclusive but shall be cumulative and in addition to existing remedies or remedies hereafter provided by law.
 

Doc Status: 
Complete