New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 505 - Charges For Professional Health Services
Section 505.32 - Nurse practitioner services
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 505.32
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Definitions.
(1) Nurse practitioner means an individual
who is licensed and currently registered as a professional nurse in the State
and who is certified under section 6910 of the Education Law as a nurse
practitioner.
(2) Nurse
practitioner services means the provision of services to a medical assistance
(MA) recipient which are in conformity with the provisions of sections 6902 and
6910 of the Education Law, regulations of
the Education Department and regulations of the Department of Health.
(3) Collaborating physician means a physician
who is not excluded from participation in either the MA or the Medicare
programs, with whom the nurse practitioner maintains practice agreements and
practice protocols in accordance with section 6902 of the Education Law.
(4) Practice agreements and practice
protocols means written documents meeting the requirements of section 6902 of the Education Law and 8 NYCRR
section 64.6 of the Education Department's regulations.
(b) Written practice agreement and practice protocols required. Written practice agreements and practice protocols between nurse practitioners and their collaborating physicians must contain the provisions required by the Education Law and regulations of the Education Department, including provisions for the collaborating physician's review of patient records at least every three months. The physician's review of patient records is not a billable service under the MA program. The nurse practitioner must make the written practice agreements and practice protocols and evidence that the collaborating physician has reviewed patient records available to the department and its agents for purposes of conducting audits under the MA program.
(c) Identification of collaborating physician required. The nurse practitioner must submit the name of and other identifying information concerning the collaborating physician with the nurse practitioner's MA enrollment application.
(d) Payment for nurse practitioner services. MA coverage for nurse practitioner services is available in accordance with the provisions of this subdivision.
(1) Except as
otherwise provided in this subdivision, payment for nurse practitioner services
must be in accordance with the fees established by the Department of Health and
approved by the Director of the Budget.
(2) Payment is available for nurse
practitioners' services which are part of the development of, or furnished
pursuant to, an individualized education program and which are provided by a
nurse practitioner employed by, or under contract to, a school district, an
approved pre-school, or a county in the State or the city of New York.
Reimbursement for such services must be made in accordance with the provider
agreement.
(3) Payment is available
for nurse practitioners' services which are part of the development of, or
furnished pursuant to, an interim or final individualized family services plan
and are provided by a nurse practitioner employed by, or under contract to, an
approved early intervention program, or a municipality in the State.
Reimbursement for such services must be made in accordance with the provider
agreement.
(4) Payment for nurse
practitioner services provided by a nurse practitioner who is paid a salary by
a medical facility which is reimbursed under the MA program for its services on
a rate basis will be made on a fee for service basis only if the cost of the
nurse practitioner services is not included in the facility's cost-based
rate.
(5) Payment will be made for
medically necessary ancillary services which are covered under the MA program
and which the nurse practitioner orders for an MA recipient. Payment will only
be made for prescription drugs when prescribed by a nurse practitioner who has
the authority to write prescriptions under the provisions of the Education Law
and regulations of the Education Department.
(e) This section is effective for services provided by nurse practitioners on and after July 1, 1990.
(f) Preferred Physicians and Children Program.
(1) Scope. The Preferred Physicians
and Children Program (PPAC) is a program under which a written agreement is
entered into by a provider and the department pursuant to which the department
pays enhanced fees for certain medical services provided to children under the
age of 21 who are eligible for medical assistance (MA). Only qualified nurse
practitioners meeting the requirements of this section are eligible to
participate in PPAC. Nurse practitioners who wish to participate in PPAC must
apply in writing on forms provided by the department. Applications for
participation will be reviewed by and must receive approval of the department
and the Department of Health. Participating nurse practitioners may obtain
payment at the enhanced fees for medical services by using special PPAC
procedure codes on their MA claims.
(2) Purpose. The purpose of PPAC is to
improve access to quality medical care for MA-eligible children by paying
enhanced MA fees to nurse practitioners meeting the criteria for PPAC
participation.
(3) Definitions.
(i) Nurse practitioner, for the purposes of
this subdivision, means a person who is licensed and currently registered
pursuant to section 6910 of the Education Law to practice
registered professional nursing which may include the diagnosis of illness and
physical conditions and the performance of therapeutic and corrective measures
within a specialty area of practice, in collaboration with a licensed physician
qualified to collaborate in the specialty involved, provided such services are
performed in accordance with a written practice agreement and written practice
protocols; the written practice agreement must include explicit provisions for
the resolution of any disagreement between the collaborating physician and the
nurse practitioner regarding a matter of diagnosis or treatment that is within
the scope of practice of both; and as defined at and in accordance with section 6902 of the Education Law.
(ii) Medical care coordination, for purposes
of this subdivision, means providing or arranging for the provision of:
(a) scheduling of elective hospital
admissions;
(b) assisting with
emergency admissions;
(c) managing
and/or participating in hospital care and discharge planning;
(d) scheduling of referral appointments with
written referrals as necessary and with requests for follow-up
reports;
(e) scheduling of
ancillary services;
(f) notifying
by telephone the social services district responsible for furnishing MA to the
recipient when transportation services are essential to ensure the MA
recipient's access to medically necessary care and services provided under the
MA program; and
(g) maintaining
complete medical records in compliance with the requirements of section
540.7 of
this Title, including, but not limited to, notation of referrals and
hospitalizations, and copies of test results and reports.
(iii) Qualified primary care nurse
practitioner, for the purposes of this subdivision, means a nurse practitioner
who:
(a) is licensed and currently registered
as a professional nurse in this State and who is certified and currently
registered as a nurse practitioner under section 6910 of the Education Law;
(b) has a collaborative agreement with a
physician who has an agreement with the MA program to participate in PPAC as a
primary care provider;
(c) provides
24-hour telephone coverage of his or her practice and ensures timely access to
a practitioner qualified to respond to patients' health care needs. This
requirement cannot be met by a recording which refers patients to emergency
rooms;
(d) provides medical care
coordination;
(e) provides periodic
health assessment examinations in accordance with the standards of the
Child/Teen Health Plan (C/THP), as set forth in Part 508 of this
Title;
(f) complies with all
applicable statutory and regulatory requirements of the MA program;
and
(g) is enrolled in the MA
program and accepted for participation in PPAC by the department and the
Department of Health.
(iv) Qualified specialist nurse practitioner,
for purposes of this subdivision, means a nurse practitioner who:
(a) is licensed and currently registered as a
professional nurse in this State and who is certified under section 6910 of the Education Law as a nurse
practitioner;
(b) has a
collaborative agreement with a physician who has an agreement with the MA
program to participate in PPAC as a qualified non-primary care specialist
physician;
(c) provides
consultation summaries or appropriate periodic progress notes to qualified
primary care physicians on a timely basis following referrals or routinely
scheduled consultant visits;
(d)
notifies the qualified primary care physician when scheduling a hospital
admission;
(e) maintains complete
medical records in compliance with the requirements of section
540.7 of
this Title, including but not limited to, notation of referrals and
hospitalizations, and copies of test results and reports;
(f) complies with all applicable statutory
and regulatory requirements of the MA program; and
(g) is enrolled in the MA program and
accepted for participation in PPAC by the department and the Department of
Health.
(4)
Written agreement required.
(i) As a
condition of participation in PPAC, each nurse practitioner must certify to the
department that he or she meets the standards for participation set forth in
either subparagraph (3)(iii) or (iv) of this subdivision.
(ii) Each qualified primary care and
qualified specialist nurse practitioner must agree in writing that:
(a) informational material provided by the
department concerning MA eligibility and services for persons under 21 years of
age and pregnant women will be conspicuously displayed on the nurse
practitioner's premises and that the nurse practitioner will request additional
informational material from the department as necessary;
(b) the nurse practitioner will notify the
department within 30 days of circumstances resulting in his or her
ineligibility to participate in PPAC and/or the inability to perform the
activities and services required under the agreement;
(c) the Department of Health has the
authority to establish fees for payment which supersede those in effect at the
time the nurse practitioner first entered into an agreement to participate in
PPAC and which are applied prospectively to services furnished under the
program by the nurse practitioner;
(d) the nurse practitioner will comply with
all policies, procedures and instructions provided by the department and the
Department of Health to implement PPAC and make claims for payment under the MA
program in accordance with the claiming procedures and the current fee
schedule;
(e) the department may
cancel the nurse practitioner's participation in PPAC at any time by providing
at least 30 days' written notice for failing to comply with standards for
participation in PPAC; and
(f) the
nurse practitioner will provide the department with at least 30 days written
notice of his or her intent to cancel the PPAC agreement, which notice must
include a description of the basis for the cancellation. The nurse practitioner
must agree to continue to provide and/or arrange for the provision of medical
services for patients up to the date of termination of the PPAC agreement, to
assist patients to maintain continuity of care, to provide patients with
information to assist them in transferring their care to another provider and
to make timely transfer of appropriate information in the patients' records
upon request.
(5) Payment.
(i) Qualified primary care and qualified
specialist nurse practitioners will be paid for their services pursuant to
their agreement with the department at fees established by the Department of
Health and approved by the Director of the Budget.
(ii) Qualified primary care and qualified
specialist nurse practitioners who provide services in free-standing or
hospital-based clinics licensed under article 28 of the Public Health Law may
not submit claims for their services using the PPAC procedure codes if the
clinic submits claims to the MA program and is paid for these services. When
the nurse practitioner's services are not included in the clinic's MA rate, the
nurse practitioner may submit claims using the regular (non-PPAC) MA procedure
codes.
(iii) Qualified primary care
and qualified specialist nurse practitioners who, either individually or as
members of a group practice, provide services in the emergency rooms of
facilities licensed under article 28 of the Public Health Law, pursuant to
contracts with those facilities, may not submit MA claims for their services
using the PPAC procedure codes. When an emergency room nurse practitioner's
services are not included in the article 28 facility's MA rate, the nurse
practitioner may submit claims using the regular (non-PPAC) MA procedure
codes.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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