New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter F - Finance; Claims for Reimbursement by Social Services Districts
Article 4 - Supplementary Assistance Reimbursement Claiming
Part 635 - Medical Assistance Reimbursement Claiming
Section 635.2 - Conditions for reimbursement for MA

(a) Costs related to the provision of MA which are required to be allocated or distributed by regulation or direction of the department shall be claimed and allocated as required by such regulations or direction. Costs shall be allocated or distributed in accordance with the requirements set forth in department regulations pertaining to the allocation of expenditures for public assistance and care.

(b) Except as otherwise directed by the department no claims shall be made for reimbursement of any portion of any payments disbursed by the department or its fiscal intermediary as payments to providers on behalf of social services districts as a function of the Medicaid Management Information System (MMIS) if such payment or other adjustment is reimbursed or charged to the district as provided by the provisions of section 367-b of the Social Services Law.

(c) Any adjustments of claims for reimbursement, including adjustments to claims as a result of recoveries or collections, shall be made in accordance with procedures, instructions or directions of the department.

(d) Amounts claimed by a social services district or other governmental agency as Federal incentives under title XIX of the Social Security Act may be retained or claimed as a portion of the Federal share of the amount collected as medical support or assigned third-party benefits when such district or agency, pursuant to an agreement with such district, has collected such medical support or third-party benefits on behalf of an MA recipient whose rights to medical support or third-party benefits have been assigned to the State or to the appropriate social services official, provided that (1) Federal participation is available for such claims, and (2) such claims are appropriately made and actually reimbursed, paid or credited to the State.

(e) No amounts shall be claimed as reimbursement for payments pursuant to title XIX of the Federal Social Security Act for benefits available under title XVIII of such act without documentation that title XVIII claims have been filed and denied.

(f) No amounts shall be claimed as reimbursement for MA if such amounts would not have been expended, or a recovery would have been made, if the district had not failed to establish the liability of and seek reimbursement from a liable third party.

(g) No amounts shall be claimed as reimbursement for payments made to providers excluded from the Medicaid program, except that such amounts may be claimed in accordance with specific directions of the department with respect to a particular provider, provided that Federal participation shall not be available to the district if it is not available to the State.

(h) Any amounts that have been recovered or could have been recovered as attributable to the MA program shall be reported and credited in accordance with Federal and State law and regulations, except that such amounts shall be reported or credited in accordance with any specific direction of the State with respect to those particular amounts, provided that Federal participation to the district may be reduced to the extent it is not available to the State.

(i) No amounts shall be claimed as reimbursement for payments made to providers or other entities when the district has been informed or otherwise should have known that payments to such entities should have been withheld, denied, reduced or otherwise not paid.

(j) Except as otherwise specifically authorized by Federal and State law or regulation or as specifically directed by the department, no amounts shall be claimed as reimbursement for payments made directly to a recipient of MA, an individual eligible to receive MA or such person's representative.

(k) Retrospective adjustments of rates of payment to providers shall be reflected in the claims of districts in accordance with directions of the department.

(l) No amounts claimed for MA reimbursement shall include expenditures for capital additions or improvements.

(m) Amounts claimed shall be reduced in accordance with instructions and directions of the department to reflect any penalty or other charges accruing to the district.

(n) Any claims for reimbursement pursuant to this Part shall not be predicated upon any rate or amount that is greater than rates or amounts permitted by the department or by the Social Services Law or other State law, regulation or policy.

(o) No amount shall be claimed as reimbursement for MA if it does not represent or relate to payment of part or all of the cost of care, services and supplies which are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with his or her capacity for normal activity or threaten some significant handicap, and which are furnished an eligible person in accordance with the Social Services Law and regulations of the department, and include care, services and supplies described in that portion of the Social Services Law relating to character and adequacy of assistance rendered as MA.

(p) Claims for MA reimbursement which do not seek Federal participation shall not be submitted to the department if such claims could be made with Federal participation, except as otherwise specifically directed by the department.

(q) Sums expended or claimed for MA reimbursement attributable to the design, development or installation of mechanized claims processing and retrieval systems meeting the conditions of the Federal Social Security Act and the United States Secretary of Health and Human Services shall be claimed at the enhanced rate of Federal participation for such expenditures.

(r) Sums expended under the MA program which are attributable to the operation of systems, attributable to compensation or training of skilled professional medical personnel and staff directly supporting such personnel or attributable to any activity for which an enhanced rate of Federal participation is available, shall be claimed at the enhanced rate of Federal participation for such expenditures.

(s) Any claims for reimbursement for expenditures which are subsequently determined by the department to be reimbursable from, or for which reimbursement is actually received or credited from, another program for which Federal participation could be received, shall be reduced in an amount equivalent to the amount determined by the department to be due as a result of the availability of Federal participation.

(t) Any claims for reimbursement from any portion of a program or activity for which Federal participation is available which were not fully reimbursed as claimed and which were properly made at the time they were originally claimed may be claimed from programs for which Federal participation is available if they could have been so claimed when originally submitted, provided that the revised claim is timely and an adjustment to reduce the original claim is simultaneously submitted to the department.