N.Y. Social Services Law § 365-g: Utilization review for certain care, services and supplies

§ 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; or

(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.

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.