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 540.5 - Authorization by public welfare officials
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 540.5
Current through Register Vol. 46, No. 39, September 25, 2024
(a) General. Whenever prior authorization for any item of medical assistance is required, the public welfare official shall give notification to the vendor in accordance with the requirements of this section.
(1) The public welfare official
shall either accept liability for the cost of the medical care requested by
issuing an authorization to the vendor containing the minimum essentials listed
below, or he shall deny responsibility by notifying the vendor in writing of
his rejection of the notification. It is desirable that the acceptance of the
notification be issued to the vendor in writing, but, if the public welfare
official prefers, he may arrange wth the vendor that acceptance of liability
may be assumed unless a notice of rejection is received by the vendor. Whether
or not the acceptance of liability is issued to the vendor in writing, a
written authorization containing the minimum essentials listed below shall be
forwarded by the authorizing official to the disbursing unit of the public
welfare agency, the information contained in such written authorization
becoming the basis for payment by the disbursing unit of the agency to the
medical vendor. Such authorizations shall be subject to the same limitations
and control as are specified in section
540.6
of this Part.
(2) Decision as to
acceptance or rejection of notification and request for authorization shall be
made as promptly as possible by the public welfare official.
(3) If the notification and request for
authorization is accepted by the public welfare official, the authorization to
the vendor (or vendors) shall contain, as a minimum, the following information:
(i) case identification and patient
designation;
(ii) effective date of
services for which public welfare official assumes liability;
(iii) expiration date of
authorization;
(iv) volume of
service authorized;
(v) type,
character or nature of services authorized;
(vi) vendor authorized to provide such
services;
(vii) source of payment
(if other than agency);
(viii)
signature of authorizing official and date of issuance;
(ix) signature of supervisor of medical
services, when required by nature of service.
(4) The agency shall utilize a form of
authorization containing such minimal information, as illustrated in section B
of illustrative form M-1, contained in the instructions of the
department.
(5)
(i) After May 14, 1976, the local social
services official shall authorize medical assistance payments only after
obtaining documentation of the following actions for persons admitted on or
after May 14, 1976 to skilled nursing facilities holding title XVIII provider
agreements:
(a) that the Commissioner of
Health or his designee has approved admission and continued stay in a skilled
nursing facility; and
(b) that the
admitting facility has prepared written justification of the decision not to
make application to Medicare because of the patient's apparent technical
ineligibility; or
(c) that
application has been made for Medicare benefits and rejected as being
ineligible; and
(d) that
reconsideration of the Medicare rejection has been initiated or, when the
skilled nursing facility agrees with Medicare's reasons for rejecting, a
written justification of their agreement has been submitted to the local
medical director.
(ii)
Skilled nursing facilities shall not be required to initiate requests for
reconsideration in cases where they agree with Medicare's rejection. The
Commissioner of Health or his designee, however, shall review the skilled
nursing facility's justifications for agreeing with Medicare. In those
instances in which the Commissioner of Health or his designee disagrees with
the Medicare rejection, the social services official shall require the skilled
nursing facility to initiate a reconsideration of Medicare's
decision.
(iii) Should the Medicare
reconsideration process fail to reverse the initial rejection, the local social
services district shall assume responsibility for insuring that a Medicare
appeal is initiated in each appropriate instance.
(iv) Appeals, when deemed to be appropriate,
must be initiated within 14 calendar days of the date of the fiscal
intermediary's notification that the reconsideration process had failed to
reverse the original decision.
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.
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