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This entry was published on 2022-07-08
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SECTION 365-G
Utilization review for certain care, services and supplies
Social Services (SOS) CHAPTER 55, ARTICLE 5, TITLE 11
§ 365-g. Utilization review for certain care, services and supplies.
1. The department may implement a system for utilization review,
pursuant to this section, for persons eligible for benefits under this
title, to evaluate the appropriateness and quality of medical
assistance, and safeguard against unnecessary utilization of care and
services, which shall include a post-payment review process to develop
and review beneficiary utilization profiles, provider service profiles,
and exceptions criteria to correct misutilization practices of
beneficiaries and providers; and for referral to the office of Medicaid
inspector general where suspected fraud, waste or abuse are identified
in the unnecessary or inappropriate use of care, services or supplies
furnished under this title.

2. The department may review utilization by provider service type,
medical procedure and patient, in consultation with the state department
of mental hygiene, other appropriate state agencies, and other
stakeholders including provider and consumer representatives. In
reviewing utilization, the department shall consider historical
recipient utilization patterns, patient-specific diagnoses and burdens
of illness, and the anticipated recipient needs in order to maintain
good health. The system for utilization review shall not be used to
determine a recipient's medical care, services or supplies under this
section.

3. The utilization review established pursuant to this section shall
not apply to developmental disabilities services provided in clinics
certified under article twenty-eight of the public health law, or
article twenty-two or article thirty-one of the mental hygiene law.

4. Utilization review established pursuant to this section shall not
apply to services, even though such services might otherwise be subject
to utilization review, when provided as follows:

(a) through a managed care program;

(b) subject to prior approval or prior authorization;

(c) as family planning services;

(d) as methadone maintenance services;

(e) on a fee-for-services basis to in-patients in general hospitals
certified under article twenty-eight of the public health law or article
thirty-one of the mental hygiene law and residential health care
facilities, with the exception of podiatrists' services;

** (f) for hemodialysis;

** NB Effective until July 1, 2023

** (f) for hemodialysis; or

** NB Effective July 1, 2023

** (g) through or by referral from a preferred primary care provider
designated pursuant to subdivision twelve of section twenty-eight
hundred seven of the public health law;

** NB Effective until July 1, 2023

** (g) through or by referral from a preferred primary care provider
designated pursuant to subdivision twelve of section twenty-eight
hundred seven of the public health law.

** NB Effective July 1, 2023

** (h) pursuant to a court order; or

** NB Repealed July 1, 2023

** (i) as a condition of eligibility for any other public program,
including but not limited to public assistance.

** NB Repealed July 1, 2023

5. The department shall consult with representatives of medical
assistance providers, social services districts, voluntary organizations
that represent or advocate on behalf of recipients, the managed care
advisory council and other state agencies regarding the ongoing
operation of a utilization review system.

6. On or before February first, nineteen hundred ninety-two, the
commissioner shall submit to the governor, the temporary president of
the senate and the speaker of the assembly a report detailing the
implementation of the utilization threshold program and evaluating the
results of establishing utilization thresholds. Such report shall
include, but need not be limited to, a description of the program as
implemented; the number of requests for increases in service above the
threshold amounts by provider and type of service; the number of
extensions granted; the number of claims that were submitted for
emergency care or urgent care above the threshold level; the number of
recipients referred to managed care; an estimate of the fiscal savings
to the medical assistance program as a result of the program;
recommendations for medical condition that may be more appropriately
served through managed care programs; and the costs of implementing the
program.