N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-4.17

Current through Register Vol. 46, No. 51, December 18, 2024

Section 86-4.17 - Appeal process

(a) An application by a facility for review of a certified or approved rate pursuant to section 86-4.16 of this Subpart shall be submitted to the bureau for staff review and shall set forth the basis for the appeal and the issues of fact. Documentation shall accompany the application, where appropriate, and the department may request such additional documentation as is necessary for determination of the issues. The affirmation or revision of the rate based upon such staff review shall be final unless, within 30 days of its receipt, a hearing before a rate review officer is requested by registered or certified mail. The request shall contain a statement of the factual issues to be resolved. The facility may submit memoranda on legal issues which it deems relevant to the appeal.

(b) Where the rate review officer determines that there is no actual issue, the request for a hearing shall be denied and the facility shall be notified of such determination. No administrative appeal shall be available from this determination. Where the rate review officer determines that there is a factual issue, a notice of hearing shall be issued establishing the date, time and place of the hearing and setting forth the factual issues as determined by such officer. The hearing shall be held in conformity with the provisions of section 12-a of the Public Health Law and the State Administrative Procedure Act.

(c) The recommendation of the rate review officer shall be submitted to the Commissioner of Health for final approval or disapproval and recertification of the rate where appropriate.

(d) In reviewing appeals for revisions to certified or approved rates, the commissioner may refuse to accept or consider an appeal from a facility:

(1) which is providing an unacceptable level of care as determined after review by the State Hospital Review and Planning Council;

(2) which is operated by management determined by the department to be providing an acceptable level of care in one of its facilities as determined after review by the State Hospital Review and Planning Council;

(3) where it has been determined by the commissioner that the operation is being conducted by a person or persons not properly established in accordance with the Public Health Law; or

(4) where a fine or penalty has been imposed on the facility and such fine or penalty has not been paid.

(e) If an appeal or application by a facility affects only the facility's article 43 rate, the facility must appeal or make application to the article 43 corporation for a change or revision in its article 43 rate within the time periods set forth in this Subpart. If the article 43 corporation recommends that such appeal or application be granted, it shall forward such recommendation to the commissioner for determination. If the article 43 corporation denies such appeal or application, the facility may, within 30 days after receipt of the denial, appeal such determination to the commissioner. The basis upon which a facility may appeal or make application for a change or revision in its article 43 rate shall be the same as the basis for an appeal or application set forth in this Subpart.

(f) If an appeal or application by a facility for a change or revision in its rate of reimbursement paid by government agencies and determined pursuant to this Subpart also affects the facility's approved article 43 rate, the facility shall forward a copy of its appeal or application to the article 43 corporation at the same time the facility submits the appeal or application to the commissioner. The article 43 corporation shall forward any recommendation for a determination of such appeal or application to the commissioner. Upon the commissioner's determination, the article 43 corporation shall send a copy of such determination to the facility.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-4.17