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Title: Section 511.8 - Determinations.

511.8 Determinations. (a) Based on the review conducted pursuant to section 511.6 of this Part, the department will issue a written determination approving, partially approving, or denying applications for increases in or exemptions from utilization thresholds, or will issue a letter pursuant to section 511.6(a)(2) of this Part advising the recipient and provider of a deficiency in the application.

(b) A copy of the written determination will be sent to the recipient, and to the provider if the provider submitted medical documentation directly to the department on the recipient's behalf. The determination will include a statement describing the recipient's fair hearing rights, and how to request a fair hearing, if a request for an increase or exemption is denied. The determination also will direct the recipient to contact the social services district for information and assistance concerning: alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to Section 2807(12) of the Public Health Law; and applying for federal disability benefits.

(c) The department will issue a written determination on an application for an increase or exemption within 25 days of receipt of the application. However, if the department requests further supporting factual or medical documentation from the recipient or the requesting provider, the time to issue a determination will be extended by the number of days from the request for additional documentation until its receipt by the department. The application will be deemed approved if the department does not make a determination within 25 days of receipt of the application or within such longer period as may be required by a request for additional documentation.



VOLUME C (Title 18)