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Title: Section 540.5 - Authorization by public welfare officials.

540.5 Authorization by public welfare officials. (a) General. Whenever prior authorization for any item of medical assistance is required, the public welfare official shall give notification to the vendor in accordance with the requirements of this section.

(1) The public welfare official shall either accept liability for the cost of the medical care requested by issuing an authorization to the vendor containing the minimum essentials listed below, or he shall deny responsibility by notifying the vendor in writing of his rejection of the notification. It is desirable that the acceptance of the notification be issued to the vendor in writing, but, if the public welfare official prefers, he may arrange with the vendor that acceptance of liability may be assumed unless a notice of rejection is received by the vendor. Whether or not the acceptance of liability is issued to the vendor in writing, a written authorization containing the minimum essentials listed below shall be forwarded by the authorizing official to the disbursing unit of the public welfare agency, the information contained in such written authorization becoming the basis for payment by the disbursing unit of the agency to the medical vendor. Such authorizations shall be subject to the same limitations and control as are specified in section 540.6 of this Part.

(2) Decision as to acceptance or rejection of notification and request for authorization shall be made as promptly as possible by the public welfare official.

(3) If the notification and request for authorization is accepted by the public welfare official, the authorization to the vendor (or vendors) shall contain, as a minimum, the following information:

(i) case identification and patient designation;

(ii) effective date of services for which public welfare official assumes liability;

(iii) expiration date of authorization;

(iv) volume of service authorized;

(v) type, character or nature of services authorized;

(vi) vendor authorized to provide such services;

(vii) source of payment (if other than agency);

(viii) signature of authorizing official and date of issuance;

(ix) signature of supervisor of medical services, when required by nature of service.

(4) The agency shall utilize a form of authorization containing such minimal information, as illustrated in section B of illustrative form M-1, contained in the instructions of the department.

(5) (i) After May 14, 1976, the local social services official shall authorize medical assistance payments only after obtaining documentation of the following actions for persons admitted on or after May 14, 1976 to skilled nursing facilities holding title XVIII provider agreements:

(a) that the Commissioner of Health or his designee has approved admission and continued stay in a skilled nursing facility; and

(b) that the admitting facility has prepared written justification of the decision not to make application to Medicare because of the patient's apparent technical ineligibility; or

(c) that application has been made for Medicare benefits and rejected as being ineligible; and

(d) that reconsideration of the Medicare rejection has been initiated or, when the skilled nursing facility agrees with Medicare's reasons for rejecting, a written justification of their agreement has been submitted to the local medical director.

(ii) Skilled nursing facilities shall not be required to initiate requests for reconsideration in cases where they agree with Medicare's rejection. The Commissioner of Health or his designee, however, shall review the skilled nursing facility's justifications for agreeing with Medicare. In those instances in which the Commissioner of Health or his designee disagrees with the Medicare rejection, the social services official shall require the skilled nursing facility to initiate a reconsideration of Medicare's decision.

(iii) Should the Medicare reconsideration process fail to reverse the initial rejection, the local social services district shall assume responsibility for insuring that a Medicare appeal is initiated in each appropriate instance.

(iv) Appeals, when deemed to be appropriate, must be initiated within 14 calendar days of the date of the fiscal intermediary's notification that the reconsideration process had failed to reverse the original decision.



VOLUME C (Title 18)