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 521 - Fraud, Waste and Abuse Prevention
Subpart 521-1 - COMPLIANCE PROGRAMS
Section 521-1.1 - Scope and applicability

Universal Citation: 18 NY Comp Codes Rules and Regs § 521-1.1

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

(a) Scope. Social Services Law requires certain persons participating in the Medical Assistance (MA) program to adopt and implement programs designed to detect and prevent fraud, waste and abuse in the MA program. Required providers may be able to detect and correct payment and billing mistakes and fraud if required to develop and implement a compliance program. This SubPart sets forth the requirements for establishing and operating effective compliance programs pursuant to section 363-d of the Social Services Law, the obligation to self-disclose overpayments, and the procedures for reviewing compliance programs.

(b) Applicability. The following persons shall be subject to the provisions of this SubPart, and shall hereinafter be referred to as "required providers":

(1) any person subject to the provisions of articles 28 or 36 of the Public Health Law;

(2) any person subject to the provisions of articles 16 and 31 of the Mental Hygiene Law;

(3) any managed care provider or managed long term care plan, which shall hereinafter be collectively, unless otherwise noted, referred to as "Medicaid managed care organization" or "MMCO;" and

(4) any other person for whom the MA program is, or is reasonably expected by the person to be, a substantial portion of their business operations.

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