N.Y. Comp. Codes R. & Regs. tit. 18 § 538.3

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

Section 538.3 - Reimbursement

(a) As required by Social Services Law § 367-u and, except for services paid by State only funds, contingent upon federal financial participation, reimbursement shall be made in accordance with fees determined by the commissioner based on and benchmarked to in-person fees for equivalent or similar services.

(b) Reimbursement shall not be made for services that do not warrant separate reimbursement as identified by the department during fraud, waste and abuse detection efforts. The department reserves the right to request additional documentation and deny payment for services deemed duplicative or included in a primary service. Any potential fraud, waste, or abuse, identified through claims monitoring or any other source, will be referred to the Office of Medicaid Inspector General.

(c)

(i) Subject to payment restrictions set forth in § 1842(n)(1) of the federal social security act and 42 C.F.R. § 414.50, reimbursement for professional services delivered via teleradiology shall be made only for the final radiology read and must be billed separately from the technical and administrative component as specified by the commissioner in administrative guidance.

(ii) Hospitals and physicians shall bill the professional and technical and administrative components separately in accordance with the relevant Radiology Fee Schedule set forth in subdivision (a) of section 533.6 of this Title.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 538.3

Adopted New York State Register September 14, 2022/Volume XLIV, Issue 37, eff. 9/14/2022