Title: Section 540.8 - Verification, payment and recording of medical bills.

540.8 Verification, payment and recording of medical bills. (a) The public welfare official, on receipt of bills rendered by vendors of medical assistance, shall cause such bills to be classified on the basis of State or local charge status of each recipient and the charges relative thereto and a verification of such bills within the scope and limitations of authorizations issued by the public welfare official for the services billed, and with the schedule of fees and rates promulgated by the public welfare official for vendor services. Where the fees and rates promulgated by the public welfare official exceed ceiling limits set by State regulations, the amount by which the charges billed exceed the State limits shall be identified and segregated for purposes of preparing proper claims for State aid.

(1) Verification of bills against authorization and against the schedule of fees and rates includes: verification of mathematical accuracy of billing; conformity with all billing requirements (properly signed, etc.); verification of technical or professional qualifications where such may affect the fee to be allowed; verification of mileage rates and total charges; etc. (Verification of such scope may necessitate provisions of internal agency examination of billings by clerical personnel, in part, and by professional personnel, in part.)

(b) The method of payment used by the public welfare official to settle approved and verified bills for medical services shall be in accordance with the provisions governing the particular plan of payment for medical services in effect in the district pursuant to State regulations with respect thereto.

(c) In issuing payments for medical services rendered, the public welfare official may find it advisable to identify the payment instrument with the particular services for which payment is being made.

(1) Where bills from an individual vendor for an individual case are settled by a one-payment transaction, the payment instrument may show an identification of the services being paid for in lieu of separate notification.

(2) Where bills of a vendor for medical services covering a group of cases are settled by a one-payment transaction, it will be desirable to furnish a statement of the services and cases covered by the payment transaction in order to reconcile the items being paid with the items billed for.

(d) Upon notification by the department that a nursing home company subject to the provisions of article 28-A of the Public Health Law, has failed to make a required payment in accordance with its mortgage with the New York State Housing Finance Agency or the New York State Medical Care Facilities Finance Agency, the public welfare official shall take such administrative steps as may be required by the department to insure that payment of all claims for services rendered by the nursing home company under the medical assistance program is made payable to the nursing home company's operating escrow reserve account for the month specified by the department. During such period, this payment procedure shall have the same effect as the unrestricted payment of an equal amount to the nursing home company.

(e) After payment of medical bills, a record shall be made:

(1) of the amounts paid to or in behalf of each individual case on the individual record of assistance granted cards maintained for each case; and

(2) of the total transactions in the general accounts maintained by the agency.

(f) Periodically, the sum total of amounts recorded on individual record of assistance granted cards should be reconciled with the control entries in the general accounts. In addition, the public welfare official may require additional records to be kept for administrative purposes.

(g) No payment shall be made for care, services, or supplies for any period of time for which a notification of noncoverability is received from the Commissioner of Health or his designee, or for any period of time for which a notice that services were unnecessary or inappropriate is received from a utilization review committee or a professional standards review organization.

 

Volume

VOLUME C (Title 18)

up