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Title: Section 98-1.17 - Audits and examinations

Effective Date


98-1.17 Audits and examinations.

(a) The commissioner, or his or her representative, and in the case of paragraph (5) of this subdivision, the superintendent, may examine at any time each MCO and all participating entities through which such MCO offers health services, as to the quality of health care services offered, and the adequacy of its provider arrangements. Such examination may include, but shall not necessarily be limited to:

(1) all records and reports relative to the number and characteristics (e.g., age and sex) of enrollees;

(2) all records and reports relative to utilization of services, by type;

(3) all records of complaints or grievances submitted by enrollees to the health maintenance organization, and the disposition thereof;

(4) evidence of the operation of a mechanism through which the enrolled population provides advice about the policies of an MCO (e.g., enrollee representation on the governing board); and

(5) contracts with providers of health services and other vendors.

(b) The superintendent, the commissioner, or their representatives, may examine the financial affairs of each MCO and all participating entities through which such MCO offers health services at any time. Such examination may include, but shall not be limited to, the following:

(1) all financial records, including statements of income and expense, budgets and related documents; and

(2) all books, records, files and other documents relating to the affairs of such organization, which are relevant to the financial examination.

(c) Every holding company and every controlled person within a holding company system shall be subject to examination by order of the commissioner, and except for PHSPs, HIV SNPs and PCPCPs, the superintendent, if he or she has reasonable cause to believe that the operations of such person may materially affect the operations, management or financial condition of any controlled MCO within the system operating in New York State, and that he or she is unable to obtain relevant information from such controlled MCO. The grounds relied upon by the commissioner, or where applicable, the superintendent for such examination shall be stated in his or her order. Such examination shall be confined to matters specified in the order.

(d) All fiscal and statistical records and reports of the MCO shall be subject to audit for a period of six years from the date of their filing with the department. This limitation shall not apply to situations in which fraud may be involved, or where the provider or an agent thereof prevents or obstructs the commissioner or superintendent from performing an audit pursuant to this section. All underlying books, records and documentation which formed the basis for the fiscal and statistical reports, including records of any holding company having a bearing on the operations of the MCO, filed by the MCO with the department, shall be kept and maintained by the MCO and holding company for a period of time not less than six years from the date of filing, or the date upon which the fiscal and statistical records were to be filed, whichever is the later date.


VOLUME A-2 (Title 10)