14 CRR-NY 841.11NY-CRR
14 CRR-NY 841.11
14 CRR-NY 841.11
841.11 Medical assistance payments for inpatient medically supervised withdrawal services.
(a) Definitions.
For the purposes of this section:
(1) Eligible inpatient medically supervised withdrawal service provider shall mean a medically supervised withdrawal service provider that has been certified by the office to provide inpatient medically supervised withdrawal services pursuant to Part 816 of this Title.
(2) Patient day shall mean the unit of measure denoting lodging provided and services rendered to one patient between the census-taking hours on two successive days. A patient day is counted on the day of admission but not on the day of discharge. When a patient is admitted and discharged on the same day, this period shall be counted as one patient day.
(3) Billable day shall mean a patient day which conforms to the following requirements:
(i) A face-to-face contact must occur between the patient and medical or clinical staff for the provision of services provided pursuant to Part 816 of this Title.
(ii) Reimbursement shall only be made for inpatient medically supervised withdrawal services provided on the site of the inpatient medically supervised withdrawal program.
(b) Calculation of fees.
Fees shall be developed for inpatient medically supervised withdrawal services. Fees will reflect geographic variations in costs. Fees shall be all inclusive and payment in full for inpatient medically supervised withdrawal services provided pursuant to Part 816 of this Title. Separate inpatient medically supervised withdrawal services fees shall be established for the upstate region and the downstate region.
(c) Fee methodology.
The fee for inpatient medically supervised withdrawal services shall be determined using a cost model based on the requirements of Part 816 of this Title and a review of historical costs for inpatient medically supervised withdrawal services. The cost model shall contain personal service and non-personal service costs. Upstate and downstate fees shall be used to recognize cost differentials between these regions of the State. Two unit fee models shall be developed: inpatient medically supervised withdrawal downstate and inpatient medically supervised withdrawal service upstate.
(d) Utilization review and control.
Utilization review and control for inpatient medically supervised withdrawal providers shall provide that:
(1) a physician must certify for each Medicaid recipient that services of the type provided are or were needed in accordance with Part 816 of this Title;
(2) the certification must be made at the time of admission or, if an individual applies for Medicaid while in the facility, at the time of application;
(3) the utilization review plan of an eligible inpatient medically supervised withdrawal provider shall include the following:
(i) provisions for review of each Medicaid recipient's need for services furnished in accordance with the criteria of Part 816 of this Title;
(ii) provisions to ensure that utilization review of a Medicaid recipient's services shall be performed by a group of professionals that includes a physician, and at least one individual who is not directly responsible for the care of the recipient nor who has a financial interest in the eligible inpatient medically supervised withdrawal provider's service who shall solely be responsible for approval of the utilization plan;
(iii) procedures to be used by the committee to ensure that staff of the eligible inpatient medically supervised withdrawal provider take needed corrective action;
(iv) provisions to ensure that the patient's record includes all information required by Part 816 of this Title, as well as the name of the patient's physician, the dates of Medicaid application and authorization if made after admission, initial and subsequent continued stay review dates, the reasons and plan for continued stay if continued stay is necessary, and other supporting material found necessary and appropriate by the utilization review group;
(v) specification of records and reports to be made by the utilization review group;
(vi) provisions for maintaining the confidentiality of the identities of patients in the records and reports of the utilization review group; and
(vii) written criteria to assess the need for continued stay which conform to the requirements of Part 816 of this Title;
(4) the group performing utilization review shall ensure that the initial review for a continued stay of a recipient in an eligible program shall be no later than the seventh day after admission. The date assigned shall be noted in the patient's record;
(5) the group performing utilization review shall ensure that subsequent reviews for continued stay of a recipient in an eligible inpatient medically supervised withdrawal provider service are conducted no later than each two-day period following the initial continued stay review. The date assigned for each subsequent continued stay review shall be noted in the patient's record;
(6) continued stay reviews shall be performed in accordance with the following:
(i) review for continued stay shall be conducted by the utilization review group or a designee of the group;
(ii) the review shall be conducted on or before the review date assigned;
(iii) the group or designee shall review and evaluate the documentation referred to in subparagraph (3)(iv) of this subdivision in relation to the criteria established in response to subparagraph (3)(vii) of this subdivision;
(iv) if the group or designee finds that a recipient's continued stay is needed, the group shall assign a new continued stay review date in accordance with this paragraph;
(v) a physician or physician assistant or nurse practitioner must certify that the services continue to be needed by each recipient;
(vi) if the group finds that a continued stay is not needed, it shall notify the recipient's attending physician and primary counselor within one working day and provide them two working days to present their views before a final decision;
(vii) if the attending physician and the primary counselor do not present additional information or agree that continued stay is unnecessary, the utilization review group decision shall be final;
(viii) if the attending physician and primary counselor present additional information or clarification, the need for continued stay shall be reviewed by the entire utilization review group and its decision shall be final;
(ix) any decision of the utilization review group that continued stay is unnecessary shall be provided in writing within two days to the director, the attending physician, the primary counselor, and the patient; and Medicaid billing shall cease as of the day of notification. However, any decision to discharge or retain the patient shall be made on clinical grounds independent of the utilization review group's determination.
14 CRR-NY 841.11
Current through May 31, 2021
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IMPORTANT NOTE REGARDING CONTENT CURRENCY: JULY 31, 2023, is the date of the most recently produced official NYCRR supplement covering this rule section. For later updates to this section, if any, please: consult editions of the NYS Register published after this date; or contact the NYS Department of State Division of Admisnistrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of the NYS Rules.