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Title: Section 540.7 - Requirements for billing.

540.7 Requirements for billing. (a) All bills for medical care, services and supplies shall contain:

(1) patient name, case number and date of service;

(2) itemization of the volume and specific types of care, services and supplies provided (including for a physician, his final diagnosis, and for drugs, the prescription filled);

(3) the unit price and total cost of the care, services and supplies provided;

(4) vendor name and address;

(5) the social security number or employer identification number of the vendor in accordance with the following:

(i) When the provider of services is in solo practice, or when the provider of supplies is in business by himself, identification shall be by social security number.

(ii) When the provider of services is in other than solo practice, identification shall depend upon the group's billing practices; e.g., where the billing is by the individual, then identification shall be by social security number.

(iii) Where billing is by a partnership or a corporation, then identification shall be by employer identification number.

(iv) Where billing is by a medical facility (e.g., hospital, skilled nursing facility or health-related facility) and such billing includes the cost of care provided by a physician, the name and social security number of the physician shall be separately stated;

(6) for the initial billing only, the following documentation for persons admitted on or after May 14, 1976 to skilled nursing facilities holding title XVIII provider agreements shall be required. Claims for medical assistance payments shall not be processed if any element of the required documentation as herein provided is not submitted by the skilled nursing home operator:

(i) a copy of the New York State Health Department's Long-Term Care Placement Form (DMS-1) or equivalent, properly and legibly completed, which was submitted for skilled nursing coverage under title XVIII;

(ii) additional forms and documents necessary to assess the patient's medical condition or need for skilled nursing home care and services and determined by the Commissioner of Health or his designee;

(iii) a written justification of the facility's decision not to submit to Medicare because of the patient's apparent technical ineligibility for coverage;

(iv) the official Medicare denial notice received from the Bureau of Health Insurance or its fiscal intermediary for this purpose; and

(v) a copy of the request for reconsideration for skilled nursing facility coverage submitted to Medicare; or, in cases where the skilled nursing facility agrees with the Medicare decision, a copy of the skilled nursing facility's justification for agreeing with the Medicare rejection;

(7) in the case of hospital bills submitted to the local department of social services for inpatient, general hospital care, services and supplies, the hospital shall maintain on file the notification of coverability made by the Commissioner of Health or his authorized representative attesting to the appropriateness and necessity of such care, services and supplies in accordance with Part 505 of this Subchapter. No billing for payment shall be made for care, services or supplies for any period of time for which coverability has not been determined by the Commissioner of Health or his designee;

(8) a dated certification by the provider that the care, services and supplies itemized have in fact been furnished; that the amounts listed are due and owing and that, except as noted, no part thereof has been paid; that payment of fees and rates made in accordance with established schedules is accepted as payment in full for the care, services and supplies provided; that there has been compliance with title VI of the Federal Civil Rights Act of 1964 in furnishing care, services and supplies without discrimination on the basis of race, color or national origin; that such records as are necessary to disclose fully the extent of care, services and supplies provided to individuals under the New York State Medicaid program will be kept for a period of not less than six years from the date of payment unless otherwise required by regulation, and information will be furnished regarding any payment claimed therefor as the local social services agency or the State Department of Social Services may request; and that the provider understands that payment and satisfaction of this claim will be from Federal, State and local public funds and that he or she may be prosecuted under applicable Federal and State laws for any false claims, statements or documents, or concealment of a material fact provided, however, that each bill need not contain the dated certification required by this paragraph in cases where the care, services or supplies (other than the services of a clinical laboratory) were furnished in a Canadian province or in a state other than the State of New York by a provider with a principal place of business outside the State of New York so long as the provider has previously filed with the department a certification containing all of the provisions required by this paragraph which will be applicable to all bills to be submitted by the provider during the period of the provider's participation in the medical assistance program.

(9) (i) Prior to payment of a bill for a service directly related to a sterilization or a hysterectomy, the State agency must be in possession of the appropriate documentation.

(ii) For sterilization this is the DSS 3134, "Sterilization Consent Form"; for hysterectomies, the DSS 3113, "Acknowledgment of Receipt of Hysterectomy Information."

(10) In the case of bills for physician services, physicians are required to maintain complete, legible records in English for each patient treated. Medical records shall include at a minimum, but not be limited to, the following:

(i) the full name, address and medical assistance program identification of each patient examined and/or treated in the office for which a bill is presented;

(ii) the date of each patient visit;

(iii) the patient's chief complaint or reason for each visit;

(iv) the patient's pertinent medical history as appropriate to each visit, and findings obtained from any physical examination conducted that day;

(v) any diagnostic impressions made for each visit;

(vi) a recording of any progress of a patient, including patient response to treatment;

(vii) a notation of all medication dispensed, administered or prescribed, with the precise dosage and drug regimen for each medication dispensed or prescribed;

(viii) a description of any X-rays, laboratory tests, electrocardiograms or other diagnostic tests ordered or performed, and a notation of the results thereof;

(ix) a notation as to any referral for consultation to another provider or practitioner, a statement as to the reason for, and the results of such consultations;

(x) a statement as to whether or not the patient is expected to return for further treatment, the treatment planned, and the time frames for return appointments;

(xi) a chart entry giving the medical necessity for any ancillary diagnostic procedure; and

(xii) all other books, records and other documents as are necessary to fully disclose the extent of the care, services and supplies provided.

(b) Bills may represent individual billing for each case served, or may represent multiple billing for a number of cases at one time, depending upon the regulations which the public welfare district shall establish. Such regulations will be governed by the plan of medical payments elected by the district pursuant to State regulations with respect thereto. In the case of multiple billing, supporting details for each service provided to each patient must be attached to the bill, unless the description of services rendered on the face of the bill is complete. (For example, a multiple bill for drug prescriptions furnished would ordinarily be supported by copies of the prescriptions, except in the unlikely situation where a druggist lists the details of a prescription on the face of the bill itself.)



VOLUME C (Title 18)