Title: Section 511.6 - Review of applications.
511.6 Review of applications. Applications for increases in or exemptions from utilization thresholds will be reviewed by an independent contractor as follows:
(a) Automated review. All applications for increases and exemptions will be subject first to an automated review.
(1) Applications for increases will be granted during the automated review process if:
(i) the amount of additional service units requested does not exceed 200 percent of the initial utilization threshold established for the particular provider service type; and
(ii) the application is complete, and the medical necessity for the increase has been certified on the State-prescribed application form by a physician, physician's assistant, nurse practitioner, or nurse midwife, other than a person who is ineligible to participate as a provider of services under the MA program; and
(iii) the MA recipient's access to MA care, services, or supplies has never been restricted under the recipient restriction program established by section 360-6.4 of this Title.
(2) If an application is incomplete or if the certification of medical necessity is made by a provider who is ineligible to participate as a provider of services under the MA program, a letter will be sent to the MA recipient and to the provider advising them of the deficiency in the application and providing instructions for reapplying.
(3) Applications will be referred to a medical review team, as described in subdivision (b) of this section, if:
(i) the application requests an exemption from a utilization threshold; or
(ii) the application requests additional service units in excess of 200 percent of the initial utilization threshold established for the particular provider service type; or
(iii) the MA recipient's access to MA care, services, or supplies was restricted in the past under the recipient restriction program established by section 360-6.4 of this Title.
(b) Medical review. (1) When an application for an increase or exemption is referred to the medical review team pursuant to the provisions of paragraph (a)(3) of this section, the medical review team will review the application to determine:
(i) the medical necessity of the requested increase or exemption;
(ii) whether the MA recipient should participate in the restricted recipient program established by section 360-6.4 of this Title; and
(iii) whether the MA recipient should be referred to appropriate and accessible managed care programs.
In its discretion, the medical review team may contact the MA recipient or the requesting provider to clarify information provided within the application, or to obtain additional information.
(2) The medical review team will consist of a registered nurse and a registered pharmacist who are licensed to practice by the State. In addition, physicians specializing in relevant areas of medicine will be available for consultation with the medical review team as needed.
(3) The criteria to be used by the medical review team in determining whether a requested increase or exemption is medically necessary are the generally accepted standards of the medical profession. With respect to requests for exemptions, the medical review team must approve such requests when medical and clinical documentation substantiates a condition of a chronic medical nature which requires ongoing and frequent use of medical care, services, or supplies such that merely increasing the threshold amount is not sufficient to meet the medical needs of the MA recipient. In accordance with section 365-g of the Social Services Law, exemptions will be approved according to the Utilization Threshold Program Exemption Guidelines (June, 1991) established by the department in consultation with the Department of Health. Copies of these guidelines may be obtained from the Department of Social Services, Division of Medical Assistance, 99 Washington Ave., Albany, NY 12210.
VOLUME C (Title 18)