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Title: Section 511.2 - Excluded services.

Effective Date


511.2 Excluded services. Utilization reviews do not apply to the following services:

(a) services furnished by or through a managed care program to persons enrolled in and receiving medical care from such program. Managed care programs include health maintenance organizations, preferred provider plans, physician case management programs or other managed medical care programs recognized by the Department;

(b) services otherwise subject to prior approval or prior authorization;

(c) reproductive health and family planning services including: diagnosis, treatment, drugs, supplies, and related counseling furnished or prescribed by a physician or under a physician's supervision;

(d) until September 1, 1992, services provided by or under the direction of a primary provider under the recipient restriction program, as established by section 360-6.4 of this Title;

(e) methadone maintenance treatment services;

(f) services provided by private practitioners on a fee-for-service basis to inpatients in general hospitals certified under Article 28 of the Public Health Law or Article 31 of the Mental Hygiene Law and residential health care facilities;

(g) hemodialysis services;

(h) obstetrical services provided by a physician, hospital outpatient department, or free-standing diagnostic and treatment center-certified under Article 28 of the Public Health Law; or

(i) services provided through or by referral from a preferred primary care provider designated pursuant to Section 2807(12) of the Public Health Law;

(j) services provided pursuant to a court order; or

(k) services provided as a condition of eligibility for any other public program, including but not limited to public assistance.




VOLUME C (Title 18)