N.Y. Comp. Codes R. & Regs. tit. 10 § 85.11

Current through Register Vol. 46, No. 50, December 11, 2024

Section 85.11 - Determinations of commissioner of health

(a) The Commissioner of Health may make a determination, as appropriate, that part or all of past, present or future inpatient care, services and supplies in a hospital are not a covered benefit under medical assistance for the needy if the hospital:

(1) has failed adequately to review, act upon, and report to the department regarding discharge information provided to the hospital which has been compiled and analyzed by the department from information submitted to it by the hospital under paragraph (4) of subdivision (e) of section 405.3, Medical Facilities - Minimum Standards;

(2) has failed to correct the deficiencies identified by the review of such discharge information;

(3) has failed to submit discharge information on the forms required under paragraph (4) of subdivision (e) of section 405.9, Medical Facilities -Minimum Standards or subdivision (c) of section 85.8 of this Part or has provided information on such forms which is not complete or not accurate;

(4) has claimed reimbursement for patients who did not meet benefit coverability definitions under this Part during a portion of or all of their inpatient hospital stay.

(5) has provided care, services and supplies in a manner which results in excessive patient stay;

(6) has failed fully to record information justifying benefit coverability of care or services provided;

(7) has failed to comply with section 405.26, Medical Facilities -Minimum Standards pertaining to utilization review;

(8) has failed to fulfill its responsibilities under this Part.

(b) Such determinations of noncoverability may be made with respect to inpatient hospital care which the commissioner's designee has previously determined to be a covered benefit under medical assistance for the needy. No determination of noncoverability shall be made pursuant to paragraphs (4), (5) and (6) of subdivision (a) of this section if the commissioner's designee has previously determined such inpatient hospital care to be a covered benefit under medical assistance for the needy and the designee was an employee of the State Department of Health.

(c) The commissioner may make a determination that certain conditions and types of inpatient hospital care, services and supplies are not a covered benefit as inpatient hospital care under medical assistance for the needy when evaluation and study of such conditions and types of care, services and supplies results in a finding that such care, services and supplies are not required to be performed on an inpatient hospital basis.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 85.11