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- VOLUME C (Title 18)
- SubChapter E - Medical Care
- Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
- Title: Part 511 - MEDICAL CARE - UTILIZATION REVIEW
Title: Part 511 - MEDICAL CARE - UTILIZATION REVIEW
Effective Date
09/13/2023
Statutory Authority
Social Services Law, Sections 20(3)(d), 34(3)(f), 363-a(2), 365-g
Volume
VOLUME C (Title 18)
- VOLUME C (Title 18)
- SubChapter E - Medical Care
- Article 1 - General
- Article 2 - Program Administration
- Part 501 - MEDICAL CARE-DEPARTMENT POLICY
- Part 502 - DISCLOSURE OF INFORMATION BY PROVIDERS AND FISCAL AGENTS
- Section 502.1 - General requirements.
- Section 502.2 - Definitions.
- Section 502.3 - Determination of ownership or control percentages.
- Section 502.4 - Disclosure by providers and fiscal agents; information on owner
- Section 502.5 - Time and manner of disclosure.
- Section 502.6 - Disclosure by providers; information related to business trans
- Section 502.7 - Disclosure by providers; information on persons convicted of
- Section 502.8 - Additional time requirements for submission of requested infor
- Part 503 (Reserved)
- Part 504 - MEDICAL CARE - ENROLLMENT OF PROVIDERS
- Section 504.1 - Policy and scope.
- Section 504.2 - Application for participation.
- Section 504.3 - Duties of the provider.
- Section 504.4 - Duties of the department.
- Section 504.5 - Denial of an application.
- Section 504.6 - Acceptance of an application.
- Section 504.7 - Continued enrollment termination.
- Section 504.8 - Audit and claim review.
- Section 504.9 - Service bureaus, billing services and electronic media billers.
- Section 504.10 - New enrollments; previously enrolled providers.
- Section 504.11 - Financial security.
- Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
- Part 505 - MEDICAL CARE
- Section 505.1 - Scope of medical assistance.
- Section 505.2 - Physicians' services.
- Section 505.3 - Drugs
- Section 505.4 - Hospital services.
- Section 505.5 - Durable medical equipment; medical/surgical supplies; orthotic and prosthetic appliances; orthopedic footwear
- Section 505.6 - Ophthalmic services.
- Section 505.7 - Laboratory Services.
- Section 505.8 - Nursing service.
- Section 505.9 - Residential health care.
- Section 505.10 - Transportation for medical care and services.
- Section 505.11 - Rehabilitation services.
- Section 505.12 - Podiatry services.
- Section 505.13 - Family planning.
- Section 505.14 - Personal care services
- Section 505.15 - Psychiatric care.
- Section 505.16 - Case management.
- Section 505.17 - Radiology services.
- Section 505.18 - Clinical psychological services.
- Section 505.19 - Standards for services rendered by physicians' assistants and specialist's assistants
- Section 505.20 - Alternate care.
- Section 505.21 - Long term home health care programs; AIDS home care programs.
- Section 505.22 - Shared health facilities.
- Section 505.23 - Home health services.
- Section 505.24 - Blood, plasma or related products.
- Section 505.25 - Ambulatory care for recipients with mental illness.
- Section 505.26 - Chemical Dependence Outpatient Medically Supervised Withdrawal Services
- Section 505.27 - Chemical Dependence Outpatient Services
- Section 505.28 - Consumer directed personal assistance program
- Section 505.29 - Foster family care demonstration programs.
- Section 505.30 - Chronic hemodialysis services in the home.
- Section 505.31 - Audiology, hearing aid services and products.
- Section 505.32 - Nurse practitioner services.
- Section 505.33 - Personal emergency response services (PERS).
- Section 505.34 - Chronic care management demonstration programs.
- Section 505.35 - Assisted living programs.
- Section 505.37 - Collateral services.
- Section 505.38 - Children’s Behavioral Health and Health Services.
- Section 505.39 - Applied Behavior Analysis
- Part 506 - DENTAL CARE
- Part 507 - HEALTH SUPERVISION AND MEDICAL CARE FOR CHILDREN
- Section 507.1 - General responsibilities for health supervision and
- Section 507.2 - Special assessments, examinations and tests required for children
- Section 507.3 - Payment for health supervision and care.
- Section 507.4 - Medical rehabilitation and mental health.
- Section 507.5 - Emergency medical treatment for children in foster care.
- Part 508 - CHILD/TEEN HEALTH PLAN (C/THP)
- Section 508.0 - Scope.
- Section 508.1 - Definitions.
- Section 508.2 - General policy.
- Section 508.3 - Identification of persons eligible for C/THP services.
- Section 508.4 - Informing persons eligible for C/THP services about C/THP.
- Section 508.5 - Provision of C/THP services.
- Section 508.6 - Identification of available providers.
- Section 508.7 - Agreements with providers.
- Section 508.8 - Standards and periodicity.
- Section 508.9 - Coordination with related programs.
- Section 508.10 - Forms and reports.
- Section 508.11 - Payment.
- Section 508.12 - Continuing care providers.
- Part 509 - TUBERCULOSIS CARE
- Part 510 - CHIROPRACTIC SERVICES
- Part 511 - MEDICAL CARE - UTILIZATION REVIEW
- Section 511.1 - Utilization review.
- Section 511.2 - Excluded services.
- Section 511.3 - REPEALED
- Section 511.4 - REPEALED
- Section 511.5 - REPEALED
- Section 511.6 - REPEALED
- Section 511.7 - REPEALED
- Section 511.8 - REPEALED
- Section 511.9 - REPEALED
- Section 511.10 - REPEALED
- Section 511.11 - REPEALED
- Section 511.12 - REPEALED
- Section 511.13 - REPEALED
- Section 511.14 - REPEALED
- Part 512 - DRUG UTILIZATION REVIEW
- Part 513 - PRIOR APPROVAL OF MEDICAL, DENTAL AND REMEDIAL CARE
- Section 513.0 - Policy, purpose and scope.
- Section 513.1 - Definitions.
- Section 513.2 - Procedure for obtaining prior approval.
- Section 513.3 - Obligations and responsibilities of recipients.
- Section 513.4 - Obligations and responsibilities of the ordering practitioner and potential provider
- Section 513.5 - Obligations and responsibilities of the Department of Health.
- Section 513.6 - Evaluation of requests.
- Section 513.7 - Determinations.
- Section 513.8 - Fair hearings.
- Part 514 - PROVIDER VERIFICATION OF RECIPIENT ELIGIBILITY AND ORDERS FOR SERVICE
- Section 514.1 - Policy.
- Section 514.2 - Introduction.
- Section 514.3 - Electronic eligibility verification system.
- Section 514.4 - Medicaid eligibility terminal (MET).
- Section 514.5 - Card swipe.
- Section 514.6 - Posting of orders for care, services or supplies.
- Section 514.7 - Clearing of orders for care, services or supplies.
- Part 515 - PROVIDER SANCTIONS
- Section 515.1 - Scope and definitions.
- Section 515.2 - Unacceptable practices under the medical assistance program.
- Section 515.3 - Authority to sanction.
- Section 515.4 - Guidelines for sanctions.
- Section 515.5 - Sanctions; effect.
- Section 515.6 - Notification.
- Section 515.7 - Immediate sanctions.
- Section 515.8 - Mandatory exclusions.
- Section 515.9 - Overpayments.
- Section 515.10 - Reinstatement.
- Part 516 - MONETARY PENALTIES
- Part 517 - PROVIDER AUDITS
- Part 518 - RECOVERY AND WITHHOLDING OF PAYMENTS OR OVERPAYMENTS
- Section 518.1 - Scope.
- Section 518.2 - Definitions.
- Section 518.3 - Liability for overpayments.
- Section 518.4 - Interest.
- Section 518.5 - Recovery of overpayments; procedure.
- Section 518.6 - Recoupment of overpayments.
- Section 518.7 - Withholding of payments.
- Section 518.8 - Recovery of overpayments pending a hearing.
- Section 518.9 - Incorporation by reference
- Part 519 - PROVIDER HEARINGS
- Section 519.1 - Scope.
- Section 519.2 - General.
- Section 519.3 - Definitions.
- Section 519.4 - Right to a hearing.
- Section 519.5 - Notice.
- Section 519.6 - Information concerning the right to a hearing.
- Section 519.7 - Request for a hearing.
- Section 519.8 - Hearing rights.
- Section 519.9 - Authorization of representative.
- Section 519.10 - Notice of hearing.
- Section 519.11 - Scheduling and adjourning the hearing.
- Section 519.12 - Withdrawal or abandonment of a request for hearing.
- Section 519.13 - Examination of file before hearing.
- Section 519.14 - Prehearing conference.
- Section 519.15 - Hearing officer.
- Section 519.16 - Who may be present at the hearing.
- Section 519.17 - Responsibilities at the hearing.
- Section 519.18 - Hearing procedure.
- Section 519.19 - Witnesses.
- Section 519.20 - Hearing record.
- Section 519.21 - Examination of the record after the hearing.
- Section 519.22 - Decision after hearing.
- Section 519.23 - Decision without hearing.
- Section 519.24 - Correction of errors.
- Section 519.25 - Compliance with decision.
- Part 520 - Tax Refund Offset for Overpayments of Medical Assistance
- Part 521 - Provider Compliance Programs
- Part 522 - PAYMENT FOR PRE-SCHOOL CHILDREN WITH HANDICAPPING CONDITIONS
- Part 527 - STATE REIMBURSEMENT FOR PAYMENT TO OUT-OF-STATE PROVIDERS OF MEDICAL CARE AND SERVICES
- Part 530 - HOSPITAL RATES
- Part 531 - REIMBURSEMENT FOR MA PROVIDED TO PRESUMPTIVELY ELIGIBLE APPLICANTS
- Part 532 - PAYMENT TO PHYSICIANS
- Part 533 - STATE REIMBURSEMENT FOR PAYMENT TO PHYSICIANS
- Section 533.1 - Payment for physician's services to hospitalized
- Section 533.2 - Definitions.
- Section 533.3 - State reimbursement.
- Section 533.4 - Medicine.
- Section 533.5 - Anesthesia and surgery.
- Section 533.6 - Radiology.
- Section 533.7 - Preferred Physicians and Children Program.
- Section 533.8 - Human immunodeficiency virus enhanced fees for physicians
- Part 535 - STATE REIMBURSEMENT FOR PAYMENT TO DENTISTS
- Part 537 - STATE REIMBURSEMENT FOR OPTOMETRIC SERVICES
- Part 538 - STATE REIMBURSEMENT FOR TELEHEALTH SERVICES
- Part 505 - MEDICAL CARE
- Article 4 - Fees and Reimbursement
- Article 5 - Procedures and Forms
- Part 540 - AUTHORIZATION OF MEDICAL CARE
- Section 540.1 - Authorization as basis for payment for medical assist
- Section 540.2 - Limitations on nonmedical assistance emergency hospital care.
- Section 540.3 - Drug prescriptions.
- Section 540.4 - Notification to public welfare official for medical services.
- Section 540.5 - Authorization by public welfare officials.
- Section 540.6 - Billing for medical assistance.
- Section 540.7 - Requirements for billing.
- Section 540.8 - Verification, payment and recording of medical bills.
- Section 540.9 - Filing of authorizations, bills and related documents.
- Section 540.10 - Claims for State aid.
- Section 540.11 - Internal administrative safeguards over medical care expendi
- Section 540.12 - Advance payments to hospitals.
- Section 540.13 - Concurrent payments to hospitals.
- Part 541 - PATIENT'S MEDICAL RECORD
- Part 542 - SUBROGATED CLAIMS TO LIABLE THIRD PARTIES
- Part 540 - AUTHORIZATION OF MEDICAL CARE
- SubChapter F - Finance; Claims for Reimbursement by Social Services Districts
- Article 1 - Reimbursement and Claims
- Part 600 - PRINCIPLES OF REIMBURSEMENT CLAIMING
- Part 601 - PROCEDURES OF REIMBURSEMENT CLAIMING
- Part 602 - COST ALLOCATION FOR REIMBURSEMENT CLAIMING
- Part 603 - REDISTRIBUTION ADJUSTMENT PROCESS FOR REIMBURSEMENT CLAIMING
- Part 608 - RETRIEVAL AND CREDIT ADJUSTMENTS FOR REIMBURSEMENT CLAIMING
- Part 609 - CONDITIONS AND STANDARDS FOR REIMBURSEMENT CLAIMING
- Article 2 - Redistributable and Interim Claiming Classification
- Article 3 - Maintenance Assistance Reimbursement Claiming
- Part 620 - PUBLIC ASSISTANCE AND CARE REIMBURSEMENT CLAIMING
- Part 621 - HOME RELIEF REIMBURSEMENT CLAIMING OTDA
- Part 625 - ASSISTANCE FOR DEPENDENT CHILDREN REIMBURSEMENT CLAIMING - OTDA
- Part 626 - FEDERALLY REIMBURSED AID TO DEPENDENT CHILDREN REIMBURSEMENT CLAIMING - OTDA
- Part 627 - CHILD SUPPORT ENFORCEMENT REIMBURSEMENT CLAIMING - OTDA
- Part 628 - CHILD CARE AND FOSTER CARE REIMBURSEMENT CLAIMING - OTDA
- Part 629 - JOBS OPPORTUNITIES AND BASIC SKILLS TRAINING REIMBURSEMENT CLAIMING - OTDA
- Article 4 - Supplementary Assistance Reimbursement Claiming
- Part 633 - SERVICES FOR RECIPIENTS AND OTHERS; REIMBURSEMENT CLAIMING - OTDA
- Part 634 - SUPPLEMENTARY SECURITY INCOME AND ASSISTANCE FOR THE AGED, BLIND AND DISABLED REIMBURSEMENT CLAIMING
- Part 635 - MEDICAL ASSISTANCE REIMBURSEMENT CLAIMING
- Part 637 - FOOD STAMPS REIMBURSEMENT CLAIMING - OTDA
- Part 638 - ENERGY ASSISTANCE REIMBURSEMENT CLAIMING - OTDA
- Part 639 - OTHER ASSISTANCE REIMBURSEMENT CLAIMING - OTDA
- Article 1 - Reimbursement and Claims
- SubChapter G - Statistics
- Part 650 - REPORTS OF PRIVATE INSTITUTIONS AND AGENCIES
- Section 650.3 - Child-caring agencies and institutions (annual financial reports).
- Section 650.4 - Hospitals or sanatoria (annual reports).
- Section 650.5 - Private homes for the aged.
- Section 650.6 - Institutions providing temporary or special care (annual statistical reports).
- Section 650.7 - Medical convalescent or nursing homes which are incorporated
- Part 651 - PUBLIC ASSISTANCE REPORTS - OTDA
- Part 653 - PERSONNEL REPORTS
- Part 655 - WELFARE MANAGEMENT SYSTEM
- Part 650 - REPORTS OF PRIVATE INSTITUTIONS AND AGENCIES
- SubChapter H - Personnel
- Part 674 - GENERAL PROVISIONS
- Part 675 - DUTIES AND RESPONSIBILITIES WITH RESPECT TO REIMBURSEMENT ON PERSONNEL
- Part 676 - PERSONAL HISTORY SUMMARY
- Part 677 - MAINTENANCE OF PERSONNEL INFORMATION
- Part 678 - PERSONNEL POLICIES
- Part 679 - SPECIFICATIONS FOR LOCAL SOCIAL SERVICES COMMISSIONER AND DEPUTY SOCIAL SERVICES COMMISSIONER
- Section 679.1 - Definitions.
- Section 679.2 - Groups of social services districts.
- Section 679.3 - Commissioners of districts in Group I: minimum qualifications
- Section 679.4 - Commissioners of districts in Group II: minimum qualifications
- Section 679.5 - Commissioners of districts in Group III: minimum qualifications
- Section 679.6 - Commissioners of districts in Group IV: minimum qualifications
- Section 679.7 - Appointment of qualified persons.
- Section 679.8 - Submission of qualifications.
- Section 679.9 - Notice of qualification.
- Section 679.10 - Deputy social services commissioner.
- Part 680 - SPECIFICATIONS FOR LOCAL SOCIAL SERVICES POSITIONS
- SubChapter I - Acquisition of Real Property for Department Purposes
- SubChapter J - Commission for the Visually Handicapped - OTDA
- Part 725 - PENSION PLAN FOR BLIND VENDING STAND OPERATORS - OTDA
- Part 726 - APPLICATION FOR AUTHORIZATION TO REPRESENT GOODS AND ARTICLES AS BLIND MADE OR PROCESSED PRODUCTS PURSUANT TO SECTIONS 396-f AND 396-g OF THE GENERAL BUSINESS LAW - OTDA
- Part 727 - CONFIDENTIAL NATURE OF RECORDS OF THE COMMISSION FOR THE VISUALLY HANDICAPPED - OTDA
- Part 728 - THE EQUIPMENT LOAN FUND FOR THE DISABLED - OTDA
- SubChapter K - Standards for Office Space and Facilities
- SubChapter L - Homeless Housing and Assistance Program
- Part 800 - HOMELESS HOUSING AND ASSISTANCE PROGRAM
- Section 800.1 - General.
- Section 800.2 - Definitions.
- Section 800.3 - Applicant eligibility.
- Section 800.4 - Community eligibility.
- Section 800.5 - Project eligibility.
- Section 800.6 - Funding limitations.
- Section 800.7 - Funding criteria and award of contracts.
- Section 800.8 - Other than project costs.
- Section 800.9 - Contract provisions and performance.
- Section 800.10 - Conflict of interests.
- Part 801 - PROMPT PAYMENT POLICY OF THE NEW YORK STATE HOMELESS HOUSING AND ASSISTANCE CORPORATION - OTDA & OCFS
- Part 900 - SHELTER FOR FAMILIES - OCFS
- Part 800 - HOMELESS HOUSING AND ASSISTANCE PROGRAM
- Chapter XX - Youth Facilities Project Guarantee Fund - OTDA & OCFS
- SubChapter E - Medical Care