N.Y. Comp. Codes R. & Regs. tit. 18 § 521-1.3

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

Section 521-1.3 - Required provider duties

(a) General. Required providers shall, as a condition of receiving payment under the MA program, adopt, implement, and maintain an effective compliance program which satisfies the requirements of this SubPart. The required provider's compliance program may be a component of more comprehensive compliance activities by the required provider so long as the requirements of this SubPart are met. Required providers must implement and maintain a compliance program, adopted pursuant to this SubPart, for the entire period that the person meets the definition of being a required provider.

(b) Record retention. A required provider shall retain all records demonstrating that it has adopted, implemented and operated an effective compliance program and has satisfied the requirements of this SubPart. The required provider shall make available to the department, OMIG, or MFCU upon request, copies of such records. Records shall be retained:

(1) by required providers for a period not less than six (6) years from the date such program was implemented, or any amendments thereto, were made; or

(2) by MMCOs in accordance with the retention periods specified in their contract with the department to participate as MMCOs.

(c) Contractors, agents, subcontractors, and independent contractors.

(1) Contractors, agents, subcontractors, and independent contractors are hereinafter referred to collectively, unless otherwise noted, as "contractor" or "contractors".

(2) The required provider shall ensure that contracts with contractors specify that the contractors are subject to the required provider's compliance program, to the extent that such contractors are affected by the required provider's risk areas and only within the scope of the contracted authority and affected risk areas.

(3) The required provider shall ensure that such contracts include termination provisions for failure to adhere to the required provider's compliance program requirements.

(4) The required provider is ultimately responsible for the adoption, implementation, maintenance, enforcement, and effectiveness of its compliance program.

(d) Risk areas. The compliance program shall apply to the required provider's risk areas, which are those areas of operation affected by the compliance program and shall apply to:

(1) billings;

(2) payments;

(3) ordered services;

(4) medical necessity;

(5) quality of care;

(6) governance;

(7) mandatory reporting;

(8) credentialing;

(9) contractor, subcontractor, agent or independent contract oversight;

(10) other risk areas that are or should reasonably be identified by the provider through its organizational experience; and

(11) for MMCOs, in addition to paragraphs (1) - (10) of this subdivision, the following risk areas:

(i) compliance with terms of the MMCO's contract with the department to participate as an MMCO;

(ii) cost reporting;

(iii) submission of encounter data to the department;

(iv) network adequacy and contracting;

(v) provider and subcontractor oversight;

(vi) underutilization;

(vii) marketing;

(viii) provision of medically necessary services;

(ix) payments and claims processing; and

(x) statistically valid service verification.

(e) The required provider shall comply with all directives of the department or OMIG with respect to the adoption, implementation and maintenance of compliance programs required by this SubPart.

(f) Certification.

(1) Required providers shall certify to the department upon enrollment and annually thereafter, using a form and manner required by OMIG and the department, that the required provider has met the requirements of section 363-d of the Social Services Law and this SubPart.

(2) Participating providers that are also required providers pursuant to this SubPart shall provide a copy of the certification, required under the preceding paragraph, to each MMCO for which they are a participating provider upon signing the provider agreement with the MMCO, and annually thereafter. MMCOs shall maintain a method for submitting such certification on the MMCO's website, which may include a dedicated email address, and shall retain such certification in accordance with the requirements of subdivision (b) of this section.

(g) Report, return and explain. Required providers shall comply with the requirements of SubPart 521-3 of this Part to report, return and explain overpayments.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 521-1.3

Adopted New York State Register December 28, 2022/Volume XLIV, Issue 52, eff. 12/28/2022