§ 365-G — Utilization review for certain care, services and supplies

§ 365-g. Utilization review for certain care, services and supplies.\n1. The department may implement a system for utilization review,\npursuant to this section, for persons eligible for benefits under this\ntitle, to evaluate the appropriateness and quality of medical\nassistance, and safeguard against unnecessary utilization of care and\nservices, which shall include a post-payment review process to develop\nand review beneficiary utilization profiles, provider service profiles,\nand exceptions criteria to correct misutilization practices of\nbeneficiaries and providers; and for referral to the office of Medicaid\ninspector general where suspected fraud, waste or abuse are identified\nin the unnecessary or inappropriate use of care, services or supplies\nfurnished under this title.\n 2. The department may review utilization by provider service type,\nmedical procedure and patient, in consultation with the state department\nof mental hygiene, other appropriate state agencies, and other\nstakeholders including provider and consumer representatives. In\nreviewing utilization, the department shall consider historical\nrecipient utilization patterns, patient-specific diagnoses and burdens\nof illness, and the anticipated recipient needs in order to maintain\ngood health. The system for utilization review shall not be used to\ndetermine a recipient's medical care, services or supplies under this\nsection.\n 3. The utilization review established pursuant to this section shall\nnot apply to developmental disabilities services provided in clinics\ncertified under article twenty-eight of the public health law, or\narticle twenty-two or article thirty-one of the mental hygiene law.\n 4. Utilization review established pursuant to this section shall not\napply to services, even though such services might otherwise be subject\nto utilization review, when provided as follows:\n (a) through a managed care program;\n (b) subject to prior approval or prior authorization;\n (c) as family planning services;\n (d) as methadone maintenance services;\n (e) on a fee-for-services basis to in-patients in general hospitals\ncertified under article twenty-eight of the public health law or article\nthirty-one of the mental hygiene law and residential health care\nfacilities, with the exception of podiatrists' services;\n (f) for hemodialysis; or\n (g) through or by referral from a preferred primary care provider\ndesignated pursuant to subdivision twelve of section twenty-eight\nhundred seven of the public health law.\n 5. The department shall consult with representatives of medical\nassistance providers, social services districts, voluntary organizations\nthat represent or advocate on behalf of recipients, the managed care\nadvisory council and other state agencies regarding the ongoing\noperation of a utilization review system.\n 6. On or before February first, nineteen hundred ninety-two, the\ncommissioner shall submit to the governor, the temporary president of\nthe senate and the speaker of the assembly a report detailing the\nimplementation of the utilization threshold program and evaluating the\nresults of establishing utilization thresholds. Such report shall\ninclude, but need not be limited to, a description of the program as\nimplemented; the number of requests for increases in service above the\nthreshold amounts by provider and type of service; the number of\nextensions granted; the number of claims that were submitted for\nemergency care or urgent care above the threshold level; the number of\nrecipients referred to managed care; an estimate of the fiscal savings\nto the medical assistance program as a result of the program;\nrecommendations for medical condition that may be more appropriately\nserved through managed care programs; and the costs of implementing the\nprogram.\n