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 5 - Procedures and Forms
Part 540 - Authorization Of Medical Care
Section 540.12 - Advance payments to hospitals
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 540.12
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Criteria for eligibility.
The department is authorized to make advance payments to hospitals which meet the following criteria:
(1) The hospital is a voluntary
not-for-profit hospital.
(2) Prior
to January 1, 1978, the hospital received regular periodic advances from a
local government unit, which advances were based on anticipated medical
assistance claims payments.
(3)
That, historically, 10 percent or 5,000 patient days of hospital inpatient
services must have been provided to Medicaid recipients who reside in a
district for which the Medicaid Management Information System (MMIS) has taken
over payment responsibility.
(b) Methods of advances.
Advance payments of medical assistance funds shall be made to hospitals in the following manner:
(1) Advance payments will be made for the
period from June 1, 1978 to November 30, 1978, which period shall be known as
the advance phase.
(2) Advance
payments will be computed on the basis of a comparison of actual monthly
payments for medical assistance to the hospital with the estimated normal
monthly payments for medical assistance services. This estimate shall be
prepared by the department. The department shall advance funds to account for a
percentage of the difference between the actual payments made and the estimated
monthly claim at the following rates:
| Month | Percent |
| June | 90% |
| July | 80% |
| August | 70% |
| September | 60% |
| October | 50% |
| November | 40% |
These rates are subject to the discretion of the commissioner. In no case shall the percentage of monies advanced ever exceed 90 percent of the difference between the estimated claim and total payments received by the hospital.
(3) The only payments to be considered in
developing the comparison referred to in paragraph (2) of this subdivision
shall be payments for claims submitted to MMIS or to those local social
services districts in whose behalf it is operating.
(4) The hospital shall certify as to the
amount of inpatient services provided to Medicaid recipients, for which it has
not yet billed, in the month for which advance payments are to be received.
This certification must be sufficient to account for the entire difference
between payments actually received and the estimate developed by the department
of the normal month's payment. In the event that such unbilled services are
less than this difference, the State will advance only a percentage of the
lesser amount.
(5) In the event
that at any time during the advance phase, the actual monthly payments to a
hospital exceed 100 percent of its estimated normal month's payment, the
department may:
(i) withhold from its next
monthly advance to that hospital the amount by which the previous month's
payment exceeded the estimated normal month's payment; or
(ii) withhold from the regular monthly
payment the amount by which the actual payment exceeds the estimated normal
month's payment. Monies withheld under this option shall be applied towards the
liquidation of any outstanding advances.
(c) Performance criteria.
In order for a facility to continue to qualify for advances, it must meet the following performance criteria:
(1) For any month during which an advance is
sought, the facility's claim submissions must equal at least 90 percent of its
average monthly submissions (trended). Of these, a reasonable percentage will
have to pass MMIS edits.
(2)
"Clean" claims must be submitted within 15 days of the discharge date in 95
percent of the cases. "Clean" claims are those which do not require submission
to other third-party payors, and which do not require eligibility or disability
determination.
(3) Where the
hospital's claiming pattern clearly indicates that the facility has
deliberately withheld claims in order to qualify for the advance, the State may
recoup its advance by withholding any payments over 100 percent of the
hospital's estimated claiming levels until the amount of the advance is
recouped.
(d) Method of recoupment.
The department shall recoup all advance payments under the following procedures:
(1) At the
close of the last payment cycle of November, each hospital's outstanding
advances shall be totalled.
(2)
Advances shall be recouped in equal installments over a period of 12 months
beginning with the month of December, 1978. The department shall deduct each
month from payments made to hospitals participating in this advancing system an
amount equal to one twelfth of all advance payments. The recoupment period may
be extended to 18 months at the discretion of the commissioner.
(3) Notwithstanding any of the foregoing
provisions of this section, the department shall be authorized to modify the
schedule of recoupments set out in paragraph (2) of this subdivision upon
certification by the State Commissioner of Health of the need for such
modification made pursuant to 10 NYCRR 86-1.36 [continued] (e)
provided, however, that any such modification shall not extend the total period
of recoupment beyond 18 months.
(e) Notwithstanding any of the foregoing provisions of this section, the department may, in its discretion, make advances on either a monthly, semimonthly or weekly basis.
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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
