N.Y. Comp. Codes R. & Regs. tit. 18 § 516.1

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

Section 516.1 - Scope and definitions

(a) Scope. Social Services Law authorizes the imposition of monetary penalties for certain violations of the Medical Assistance (MA) program. This Part shall apply to monetary penalties imposed by the Office of the Medicaid Inspector General (OMIG) pursuant to sections 145-b (4), 363-d, and 364-j (38) of the Social Services Law. Nothing in this Part shall preclude or limit the Department of Health's ability to impose or levy fines or penalties or take any administrative actions under other provisions of this Title.

(b) Definitions. For purposes of sections 145-b (4), 363-d, and 364-j (38) of the Social Services Law, and this Part, the terms defined in Parts 504, 515 and 521 of this Title, except as may be provided for herein, and the following terms apply:

(1) "Encounter" means all encounter records, or adjustments to previously submitted records, which the managed care provider or managed long term care plan (MLTCP) has received and processed from provider encounter or claim records of all contracted services rendered to an enrollee of the managed care provider or MLTCP in the current or any preceding month.

(2) "Failure to grant timely access to records and facilities" means the failure to produce or make available for review, copying, and inspection requested material, or to provide access to facilities upon reasonable notice by the deadline specified in the written request made by OMIG, the department, or the deputy attorney general for Medicaid Fraud Control.

(3) "Item or service" means all medical care, services or supplies claimed to have been provided or furnished to a recipient of the MA program and which is listed in an itemized claim for payment or encounter.

(4) "Office of the Medicaid Inspector General" or "OMIG" means the independent office within the department established pursuant to Title 3 of Article 1 of the New York State Public Health Law.

(5) "Person" is as defined in Part 504 of this Title, except for monetary penalties imposed pursuant to section 145-b (4) of the Social Services Law. For purposes of section 145-b (4) of the Social Services Law "person" is as defined in that section.

(6) "Standards of generally accepted practice" means the degree of knowledge, skill and diligence possessed by, or required of, the average member of the profession or specialty which is practiced. Standards of generally accepted practice also include those practices which are accepted as effective and appropriate by the medical and scientific community of this State.

(7) "Standards of the MA program" include but are not limited to the standards set forth in the rules, regulations, and official directives of the department.

(8) "Substantial number of cases" means five percent or more of those claims, encounters, or cases identified in any audit, investigation or review, or any sample of cases which were the subject of an audit or otherwise reviewed by the department and for which claims were submitted by a person for payment under the MA program.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 516.1

Adopted New York State Register October 21, 2020/Volume XLII, Issue 42, eff. 10/21/2020