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Title: Section 511.1 - Utilization review.

Effective Date


Section 511.1 Utilization review. In accordance with section 365-g of the Social Services Law, the department may implement utilization reviews which apply to certain care, services, and supplies for medical assistance (MA) recipients. Utilization review evaluates the appropriateness and quality of medical assistance, and safeguards against unnecessary utilization of care and services; including post-payment review process to develop and review  beneficiary utilization profiles, provider services profiles and exceptions criteria to correct misutilization practice of beneficiaries and providers; and for referral to the Office of the Medicaid Inspector General where suspected fraud, waste or abuse are identified in the unnecessary or inappropriate use of care, service or supplies.


VOLUME C (Title 18)