Title: Section 86-4.16 - Revisions in certified rates

86-4.16 Revisions in certified rates.

(a) The commissioner shall consider only those applications for prospective revisions of certified or approved rates which are in writing and which address one or more of the issues set forth in this section.

(b) Errors, whether mathematical or clerical, made by the department or an article 43 corporation in the rate calculation process or in the development of group ceilings, and errors, whether mathematical or clerical or otherwise, in data submitted by a facility, when the revised data submitted meet the same certification requirements as the original data, may be the basis for an application for prospective revision of a certified or approved rate. Such errors may include, but shall not be limited to, the following areas related to the development of reimbursable costs:

(1) funding of depreciation, capital costs, patient visits/procedure; and

(2) nonallowable costs, such as revenue recoveries. Applications pursuant to this subdivision must be submitted within 120 days of receipt of the applicable title XIX or article 43 corporation program initial rate computation sheet. Any modified rate certified or approved pursuant to this paragraph shall be effective the first day of the rate period. If not commenced within 120 days of receipt of the commissioner's initial rate computation sheet, a rate appeal pursuant to this subdivision may be initiated at time of audit of the base-year cost figures upon or prior to receipt of the notice of program reimbursement. Such rate appeals shall be recognized only to the extent that they are based upon mathematical or clerical errors in cost and/or statistical data originally submitted by the facility, or revisions initiated by a third-party fiscal intermediary or, in the case of a governmental facility, by the sponsor government, or mathematical or clerical errors made by the Department of Health. Such notice of appeal must be presented in writing prior to or at the exit conference for such audits.

(c) Documented increases in the overall operating costs of a facility resulting from the implementation of additional or expanded programs, staff or services specifically mandated for the facility by the commissioner may be the basis for an application for prospective revision of a certified or approved rate. An appeal may be submitted pursuant to this subdivision at any time throughout the rate period, or within 60 days after the end of the rate period. Any modified rate certified or approved pursuant to this subdivision shall be effective on the date additional staff not reflected in the base year is hired by the facility.

(d) Documented increases in overall operating costs of a facility resulting from capital renovation, expansion, replacement or the inclusion of new programs, staff or services approved by the commissioner through the certificate of need (CON) process may be the basis for an application for revision of a certified rate, provided, however, that such CON approval shall not be required with regard to such applications for rate revisions which are submitted by federally qualified health centers or rural health centers which are exempt from such CON approval pursuant to section 2807-z of the Public Health Law. To receive consideration for reimbursement of such costs in the current rate year, a facility shall submit, at the time of appeal or as requested by the commissioner, detailed staffing documentation, proposed budgets and financial data, anticipated utilization expressed in terms of threshold visits and/or procedures and, where relevant, the final certified costs of construction approved by the department. An appeal may be submitted pursuant to this paragraph at any time throughout the rate period. Any modified rate certified or approved pursuant to this paragraph shall be effective on the date the new service or program is implemented or, in the case of capital renovation, expansion or replacement, on the date the project is completed and in use.

(e) Upon receipt of actual cost data for appeals pursuant to subdivisions (c)and (d) of this section, the modified rate based on projections will be retroactively revised to reflect actually incurred costs held to operating cost ceiling limitations and utilization standards set forth in this Subpart.

(f) Appeals pursuant to subdivision (c) or (d) of this section for subsequent rate periods must be submitted for each subsequent period within 120 days of receipt of the commissioner's initial rate computation sheet for that year.

(g) Appeals to adjustments made as a result of audits conducted by the Department of Health may be the basis for an application for rate revision. The specific items of appeal and any material documentation necessary to support provider's position must be submitted within 30 days of the receipt of the audit.