New York Codes, Rules and Regulations
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 4 - Fees and Reimbursement
Part 535 - State Reimbursement For Payment To Dentists
Section 535.3 - State reimbursement

Current through Register Vol. 45, No. 13, March 29, 2023

[Additional statutory authority: Social Welfare Law, §§ 365-b, 368-a]

(a) State and local charges.

(1) State reimbursement for local charges shall be based on payments actually made, except that in no case shall reimbursement be available for amounts paid in excess of the maximum reimbursable allowance hereinafter prescribed.
(i) If a service or procedure, which is not listed in section 535.5 of this Part, is necessarily performed, reimbursement shall be based on the expenditures actually made therefor, in accordance with applicable rules of the board and regulations of the department.

(2) The full amount paid for dental care for State charges shall be eligible for reimbursement, provided that such payment is the same as that which would be made for local charges in similar circumstances.

(b) Reimbursement for payment of dental fees.

(1) Payments for dental services under the medical assistance program shall be reimbursable by the State only when the services were rendered by a general or specialist practitioner of dentistry meeting the qualifications therefor as set forth in section 506.1 of the regulations of the department or when the services were provided in a dental clinic affiliated with State University of New York at Buffalo School of Dentistry, Columbia University School of Dental and Oral Surgery or New York University College of Dentistry and performed under the supervision of a general or specialist practitioner of dentistry meeting the qualifications therefor as set forth in section 506.1 of the regulations of the department.

(2) Reimbursement for consultation fee expenditures shall be available only when an examination is made by an accredited specialist within the scope of his specialty upon the request of the attending dentist who is treating the dental problem for which consultation is required. The attending dentist shall certify that he requested the consultation and that it was necessary for the further care of the patient.
(i) When the consultant dentist assumes the continuing care of the patient, any subsequent services rendered by him shall not be considered as consultation.

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