New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 588 - Medical Assistance Payment For Outpatient Programs
Section 588.12 - Enforcement of utilization review

(a) A provider of service shall exercise due diligence in complying with the requirements of this Part. Due diligence means the exercise of reasonable and appropriate efforts to ensure that reimbursement is sought only for the number of visits, duration of visits and services authorized in accordance with this Part and Part 587 of this Title, and that the treatment planning and service planning process is implemented pursuant to section 587.16 or 587.17 of this Title, and this Part.

(b) To facilitate determinations as to whether providers are exercising the requisite due diligence and are otherwise in compliance with this Part, the Office of Mental Health shall develop and maintain profiles of behavior of providers of service which shall permit comparison of data derived from the reimbursement practices of providers of service.

(c) If, based on a review of profiles of behavior and such additional information as may be available, the Office of Mental Health determines that a provider of service is not exercising due diligence in complying with the requirements of this Part, the Office of Mental Health shall give notice of the deficiency to the provider of service and may also initiate the following:

(d) If the provider of service fails to prepare an acceptable plan of correction within a reasonable time or refuses to permit the Office of Mental Health to provide technical assistance or fails to promptly or effectively implement a plan of correction which has been approved by the Office of Mental Health, it shall be determined that the provider of service is in violation of this Part.

(e) Upon a determination that a provider of service is in violation of this Part or upon a determination that a provider of service has failed to otherwise comply with the terms of its operating certificate or with the provisions of any applicable statute, rule or regulation, the commissioner may revoke, suspend or limit the provider's operating certificate or impose fines in accordance with Mental Hygiene Law, section 31.16 and Parts 573 and 503 of this Title.

(f) Notwithstanding the provisions of this section, if a provider of service seeks reimbursement in excess of the limits imposed in sections 588.9(a)(2) and (3), 588.10(a)(2) and (3) and 588.13(a)(3)(i), (ii) and (iii) of this Part, the provider shall be presumed to have knowingly and intentionally violated the provisions of this Part, whereupon the Office of Mental Health shall notify the Department of Social Services in order that the Department of Social Services may exercise its authority to recover such overpayments as may have occurred.

(g) Nothing in this section shall limit or preclude the commissioner from taking whatever immediate measures may be necessary, including the exercise of his authority under Mental Hygiene Law, sections 31.16(b) and 31.28, in the event that a recipient's health or safety is in imminent danger or there exists any condition or practice which poses imminent danger to the health or safety of any recipient or the public.