Current through Register Vol. 46, No. 39, September 25, 2024
(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.
