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Title: Section 86-1.32 - Administrative rate appeals

Effective Date


86-1.32 Administrative rate appeals.

(a) Administrative rate appeals of rates of payment issued pursuant to this Subpart must be submitted to the department in writing within 120 days of the date such rates are issued by the department to the facility. Such rate appeals must set forth in detail the basis for such appeal and be accompanied by any relevant documentation. Thereafter the department shall respond to such rate appeals in writing and shall either affirm the original rates, revise such rates or request additional information. A failure to respond to the department's request for additional information within 30 days shall be deemed to constitute the withdrawal, with prejudice, of the facility's rate appeal, provided, however, that the department may extend that time period upon a request by the facility and for good cause shown. Upon its receipt of the requested additional information the department shall issue a written determination of such rate appeal.

(b) The department's written determination of a facility's rate appeal shall be deemed final unless the facility submits a written request for further consideration of the rate appeal within 30 days of the date the department issued such written determination, provided, however, that if such written determination advises the facility that its rate appeal is being denied on the ground that the appeal constitutes a challenge to the rate-setting methodology set forth in this Subpart, such denial shall be deemed to be the department's final administrative determination with regard to such appeal and there shall be no further administrative review available. The department shall otherwise respond in writing to such further appeal and either affirm or revise its original rate appeal determination and this response by the department shall be deemed its final administrative determination with regard to such rate appeal.

(c) Rate appeals which are rejected or precluded on the grounds of being untimely may be considered in connection with subsequent audits conducted pursuant to section 86-1.4 of this Subpart.

(d) The department shall consider only those rate appeals that reflect one or more of the following bases.

(1) Mathematical or clerical errors in the financial and/or statistical data originally submitted by the medical facility, including information reported to the New York State Statewide Planning and Research Cooperate System (SPARCS) in accordance with section 400.18 of this Title, or mathematical or clerical errors made by the department. Revised data submitted by a facility must meet the same certification requirements as the original data and the department may require verification of revised SPARCS data by an independent review agent at the cost of the facility; and

(2) Any errors regarding a medical facility's capital cost reimbursement.

(3)(i) Direct medical education (DME) and indirect medical education (IME) costs, as defined in sections 86-1.15(f)(1) and (f)(2) of this Subpart, for hospitals where the teaching status has changed from non-teaching to teaching.

(ii) The effective date of the initial rate adjustment shall be the later of the first of the month following 60 days from the department's receipt of the written notification with documentation requesting a rate adjustment or July 1st of the program year.

(e) The department may refuse to accept or consider a rate appeal from a facility that:

(1) is providing an unacceptable level of care as determined after review by the State Hospital Review and Planning Council; or

(2) is operated by the same management that operates a facility with regard to which a determination of an unacceptable level of care has been made in accordance with paragraph (1) of this subdivision; or

(3) has been determined by the department as being operated by a person or persons not properly established or licensed pursuant the Public Health Law; or

(4) is delinquent in the payment of a fine or penalty imposed on the facility pursuant to the Public Health Law.


VOLUME A-2 (Title 10)