N.Y. Comp. Codes R. & Regs. tit. 18 § 511.1

Current through Register Vol. 46, No. 36, September 4, 2024

Section 511.1 - Utilization review

(a) 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.

(b) Within a benefit year, as defined in section 511.4 of this Part, the MA program will pay for care, services and supplies provided to eligible recipients up to and including the number of service units established as a utilization threshold for the particular provider service type. A service unit is defined as one encounter, procedure, or formulary code, depending upon the provider service type.

(c) After a recipient has reached the utilization threshold established for a particular provider service type, the MA program will not pay for additional care, services or supplies for that provider service type unless one of the following conditions is satisfied:

(1) the department has exempted the recipient from the utilization threshold;

(2) the department has granted the recipient an increase in the utilization threshold;

(3) the provider certifies that the care, services, or supplies were furnished to address an urgent medical need. An urgent medical need exists when a patient has an acute or active medical problem which, if left untreated, could reasonably result in an increase in the severity of the symptoms of the problem, an increase in the patient's recovery time, or a medical emergency; or

(4) the provider certifies that the care, services or supplies were furnished to address a medical emergency. Emergency services are medical care, services or supplies provided after a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical treatment could reasonably result in serious impairment of bodily functions, serious dysfunction of a bodily organ or body part, or would otherwise place the recipient's health in serious jeopardy.

(d) The utilization thresholds for select provider service types are set forth in sections 511.10 through 511.13 of this Part.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 511.1

Amended New York State Register September 13, 2023/Volume XLV, Issue 37, eff. 9/13/2023