N.Y. Comp. Codes R. & Regs. tit. 18 § 513.1

Current through Register Vol. 46, No. 45, November 2, 2024

Section 513.1 - Definitions

For purposes of this Part, the following terms have the following meanings:

(a) Prior approval means a determination by the Department of Health that medical, dental and remedial care, services or supplies are medically necessary to prevent, diagnose, correct or cure a condition of the recipient which:

(1) causes acute suffering;

(2) endangers life;

(3) results in illness or infirmity;

(4) interferes with the capacity for normal activity; or

(5) threatens to cause a significant handicap.

Prior approval must be obtained for certain medical, dental and remedial care, services or supplies before they are furnished or payment cannot be made for them under the MA program.

(b) Request means an application for prior approval of medical, dental and remedial care, services or supplies to be furnished under the MA program. A request must be submitted, on behalf of a recipient, through the potential provider of the care, services or supplies on the forms and in the manner required by this department and the Department of Health.

(c) Necessary to prevent, diagnose, correct or cure a condition means that requested medical, dental and remedial care, services or supplies would: meet the recipient's medical needs; reduce the recipient's physical or mental disability; restore the recipient to his or her best possible functional level; or improve the recipient's capacity for normal activity. Necessity to prevent, diagnose, correct or cure a condition must be determined in light of the recipient's specific circumstances and the recipient's functional capacity to use or make use of the requested care, services or supplies and appropriate alternatives.

(d) Ordering practitioner means the physician or dentist, osteopath, optometrist, or other health care practitioner specified in Part 505 of this Title who has a patient relationship with the recipient when a request for prior approval is filed, who has not been suspended or excluded from, or denied enrollment or re-enrollment in, the MA program and who has ordered or prescribed the medical, dental and remedial care, services or supplies for which a request is being submitted on behalf of a recipient.

(e) Potential provider means a physician or dentist, osteopath, optometrist, or other health care practitioner or enrolled provider specified in Part 505 of this Title who has not been suspended or excluded from, or denied enrollment in, the MA program, who will be furnishing the medical, dental and remedial care, services or supplies for which a request is being submitted on behalf of a recipient, and who files the request for prior approval.

(f) Recipient means a recipient of MA benefits under title 11 of article 5 of the Social Services Law, or his or her authorized representative.

(g) Treating practitioner means a physician or dentist, osteopath, optometrist, or other health care practitioner specified in Part 505 of this Title who has had an on-going patient relationship with the recipient and who has not been suspended or excluded from, or denied enrollment or re-enrollment in, the MA program.

(h) Benefit limits means specified Medicaid coverage limits which cannot be exceeded by obtaining prior approval or authorizations and for which no exceptions are allowed.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 513.1