N.Y. Comp. Codes R. & Regs. tit. 14 § 841.13

Current through Register Vol. 46, No. 25, June 18, 2024

Section 841.13 - Utilization Review

(a) Except as otherwise specified, programs shall provide that:

(1) An Office approved tool was utilized to identify the appropriate level of care for treatment delivered to the patient.

(2) A practitioner must certify for each Medicaid recipient that services of the type provided are or were needed in accordance with the controlling Part under this Title.

(3) The utilization review plan of an eligible provider shall ensure that each provider have policies and procedures to address:

(i) Patients continue to require services furnished in accordance with the applicable criteria of the controlling Part of this Title and review of treatment planning and progress notes;

(ii) Patients are receiving care consistent with psychosocial needs and diagnosis for which they are receiving treatment; and,

(iii) patients have been referred for additional services consistent with their health and physical.

(4) Providers shall have policies and procedures for a utilization management team charged with meeting at least twice annually. Such team shall review the results of audits, utilization management process and other quality assurance activities that are related to charting and to create a comprehensive corrective action plan as needed to ensure compliance with state and federal laws, regulations and guidance issued by the Office.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 841.13

Amended New York State Register December 9, 2015/Volume XXXVII, Issue 49, eff. 11/20/2015

Adopted New York State Register January 26, 2022/Volume XLIV, Issue 04, eff. 1/26/2022