N.Y. Comp. Codes R. & Regs. tit. 18 § 513.0

Current through Register Vol. 46, No. 45, November 2, 2024

Section 513.0 - Policy, purpose and scope

(a) Policy. Where prior approval of medical, dental and remedial care, services or supplies is required under the MA program, such prior approval will be granted when the medical, dental and remedial care, services or supplies are shown to be medically necessary to prevent, diagnose, correct or cure a condition of the recipient which:

(1) causes acute suffering;

(2) endangers life;

(3) results in illness or infirmity;

(4) interferes with the capacity for normal activity; or

(5) threatens to cause a significant handicap.

(b) Purpose.

(1) The department, as the single State agency supervising the administration of the MA program, has entered into an interagency agreement with the Department of Health whereby that department will review and approve selected medical, dental and remedial care, services and supplies prior to their being furnished. The purpose of this process is to assure that: the requested medical, dental and remedial care, services or supplies are medically necessary and appropriate for the individual recipient's medical needs; other adequate and less expensive alternatives have been explored and, where appropriate and cost effective, are approved; the request does not exceed benefit limitations as promulgated by the department; and the medical, dental and remedial care, services or supplies to be provided conform to accepted professional standards. The department shall not allow exceptions to defined benefit limitations.

(2) Under the interagency agreement with the Department of Health, that department reviews and determines the medical necessity and appropriateness of the medical, dental and remedial care, services or supplies to be provided. However, as the single State agency supervising the administration of the MA program, the department retains the authority and responsibility to exercise administrative discretion in the supervision of the program and make decisions with respect to the application of the rules, regulations and policies of the MA program.

(c) Scope. This Part sets forth the requirements and procedures for obtaining prior approval of medical, dental and remedial care, services or supplies under the MA program, except for transportation, orthodontics, home health care, personal care, and out-of-State services. Prior approval for these services must be obtained in accordance with the specific procedures described in this Title and Title 10 NYCRR governing those services. This Part does not govern the requirements and procedures for obtaining prior authorization of medical, dental and remedial care, services or supplies under the MA program as may be required by this Title. Prior authorizations must be obtained in accordance with the specific procedures described in this Title governing the care, services and supplies subject to prior authorization.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 513.0