N.Y. Comp. Codes R. & Regs. tit. 18 § 601.4

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

Section 601.4 - Claim adjudication

The department will be responsible for examining claims for reimbursement submitted by social services districts. Initial determinations objecting to the allowability of a claim for reimbursement will be made in a timely manner not to exceed 90 days from the time of receipt by the department, unless the department notifies a district that a specified amount of additional time, not to exceed an additional 90 days, is necessary to complete examination of the claim. Any portion of a claim to which there is no initial determination objecting to allowability will be processed for submission for acceptance by a reimbursement authority. Processing will be commenced in a timely manner not to exceed 90 days from the time of receipt of the claim or from the date of an initial determination of allowability. A determination by the department concerning the allowability of a claim for reimbursement submitted by a social services district is final and is not subject to administrative review.

(a) Acceptance or payment by the department of any portion of any claim for such reimbursement does not preclude the department from subsequently examining any portion of such claim and determining that such claim was not subject to reimbursement or should have been reimbursed at a different rate.

(b) Acceptance by the district of reimbursement from the department related to specific reimbursable costs claimed by the district precludes the district from subsequently submitting any additional claims for reimbursement for such costs without the consent of the department.

(c) Acceptance by a social services district of a determination by the department with respect to the allowability of costs or other items purported to be subject to reimbursement on any portion of any claim precludes the district from submitting any additional claims for reimbursement relating to such costs or items without the consent of the department.

(d) Any portion of any costs or other items purported to be subject to reimbursement which are determined to be unacceptable by the department may not be resubmitted for reimbursement or otherwise adjusted without the explicit consent of the department.

(e) The department may request the district to submit, or at the department's option prepare on behalf of the district, a statement of adjustments to any portion of any claim submitted by a district. Any adjustments made by the department to payments or claims for the district constitutes notification of the adjustment when the district receives a copy of the adjustment or has been notified that the adjustment has been made.

(f) Any disallowances, recoupments or adjustments resulting from the action or determination of a Federal or other reimbursement authority must be reflected in adjustments to claims as directed by the department. A copy of any adjustments made by the department constitutes notification to the district of the adjustments when the district receives a copy of the adjustment or is notified that the adjustment has been made. If the determination of the Federal or other reimbursement authority is not final or binding, or if the department has appealed or judicially challenged such determination and the district is so notified, the determination of the department with respect to the district shall not be final and binding until the determination is final and binding upon the department and the district is so notified.

(g) Any adjustments resulting from a post-claim review or audit must be reflected in adjustments to claims as directed by the department. A copy of any adjustments made by the department constitutes notification to the district of the adjustment when the district receives a copy of the adjustment or has been notified that the adjustment has been made.

(h) Any other reductions, recoupments or adjustments must be reflected in adjustments to claims as directed by the department. Such reductions, recoupments or adjustments when made by the department are final and binding when the district is notified that the reduction, recoupment or adjustment has been or will be made.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 601.4