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 521-1.2 - Definitions
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 521-1.2
Current through Register Vol. 46, No. 39, September 25, 2024
(a) For purposes of this SubPart, the terms defined in Parts 504 and 515 of this Title, except as otherwise noted, shall apply.
(b) In addition, for the purposes of this SubPart, the following terms have the following meanings:
(1) "Affected
individuals" means all persons who are affected by the required
provider's risk areas including the required provider's employees, the chief
executive and other senior administrators, managers, contractors, agents,
subcontractors, independent contractors, and governing body and corporate
officers.
(2)
"Days" means, unless otherwise noted, calendar days.
(3) "Effective compliance
program" means a compliance program adopted and implemented by the
required provider that, at a minimum, satisfies the requirements of this
SubPart and that is designed to be compatible with the provider's
characteristics (i.e., size, complexity, resources, and culture), which shall
mean that it:
(i) is well-integrated into the
company's operations and supported by the highest levels of the organization,
including the chief executive, senior management, and the governing
body;
(ii) promotes adherence to
the required provider's legal and ethical obligations; and
(iii) is reasonably designed and implemented
to prevent, detect, and correct noncompliance with MA program requirements,
including fraud, waste, and abuse most likely to occur for the required
provider's risk areas and organizational experience.
(4) "MA" means medical
assistance for needy persons provided under Title 11 of Article 5 of the Social
Services Law.
(5) "Managed
care provider" is as defined in subdivision 1 of section 364-j of
the Social Services Law.
(6)
"Managed long term care plan" or "MLTCP" means an entity that
has received a certificate of authority pursuant to section 4403-f of
the Public Health Law to provide or arrange for health and long term care
services on a capitated basis for a population which the plan is authorized to
enroll.
(7) "Medicaid Fraud
Control Unit" or "MFCU" means the Attorney General of
the State of New York operating the program required by 42 C.F.R. Part 1007 and
the Social Security Act.
(8)
"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.
(9) "Organizational
experience" means the required provider's:
(i) knowledge, skill, practice and
understanding in operating its compliance program;
(ii) identification of any issues or risk
areas in the course of its internal monitoring and auditing
activities;
(iii) experience,
knowledge, skill, practice and understanding of its participation in the MA
program and the results of any audits, investigations, or reviews it has been
the subject of; or
(iv) awareness
of any issues it should have reasonably become aware of for its category or
categories of service.
(10) "Participating
provider" means a provider of medical care and/or services that has a
provider agreement with an MMCO.
(11) "Substantial portion of business
operations" means:
(i) when a person
claims or has claimed, or should be reasonably expected to claim, at least one
million dollars ($1,000,000), in the aggregate, in any consecutive twelvemonth
period, directly or indirectly, from the MA program; or
(ii) when a person receives or has received,
or should be reasonably expected to receive, at least one million dollars
($1,000,000), in the aggregate, in any consecutive twelve-month period,
directly or indirectly, from the MA program.
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