N.Y. Comp. Codes R. & Regs. Tit. 10 § 86-4.16 - Revisions in certified rates
(a)
The commissioner shall consider only those applications for prospective
revisions of certified or approved rates which are in writing and which address
one or more of the issues set forth in this section.
(b) Errors, whether mathematical or clerical,
made by the department or an article 43 corporation in the rate calculation
process or in the development of group ceilings, and errors, whether
mathematical or clerical or otherwise, in data submitted by a facility, when
the revised data submitted meet the same certification requirements as the
original data, may be the basis for an application for prospective revision of
a certified or approved rate. Such errors may include, but shall not be limited
to, the following areas related to the development of reimbursable costs:
(1) funding of depreciation, capital costs,
patient visits/procedures; and
(2)
nonallowable costs, such as revenue recoveries. Applications pursuant to this
subdivision must be submitted within 120 days of receipt of the applicable
title XIX or article 43 corporation program initial rate computation sheet. Any
modified rate certified or approved pursuant to this paragraph shall be
effective the first day of the rate period. If not commenced within 120 days of
receipt of the commissioner's initial rate computation sheet, a rate appeal
pursuant to this subdivision may be initiated at time of audit of the base-year
cost figures upon or prior to receipt of the notice of program reimbursement.
Such rate appeals shall be recognized only to the extent that they are based
upon mathematical or clerical errors in cost and/or statistical data originally
submitted by the facility, or revisions initiated by a third-party fiscal
intermediary or, in the case of a governmental facility, by the sponsor
government, or mathematical or clerical errors made by the Department of
Health. Such notice of appeal must be presented in writing prior to or at the
exit conference for such audits.
(c) Documented increases in the overall
operating costs of a facility resulting from the implementation of additional
or expanded programs, staff or services specifically mandated for the facility
by the commissioner may be the basis for an application for prospective
revision of a certified or approved rate. An appeal may be submitted pursuant
to this subdivision at any time throughout the rate period, or within 60 days
after the end of the rate period. Any modified rate certified or approved
pursuant to this subdivision shall be effective on the date additional staff
not reflected in the base year is hired by the facility.
(d) Documented increases in overall operating
costs of a facility resulting from capital renovation, expansion, replacement
or the inclusion of new programs, staff or services approved by the
commissioner through the certificate of need (CON) process may be the basis for
an application for revision of a certified rate, provided, however, that such
CON approval shall not be required with regard to such applications for rate
revisions which are submitted by federally qualified health centers or rural
health centers which are exempt from such CON approval pursuant to section
2807-z of the Public Health Law. To
receive consideration for reimbursement of such costs in the current rate year,
a facility shall submit, at the time of appeal or as requested by the
commissioner, detailed staffing documentation, proposed budgets and financial
data, anticipated utilization expressed in terms of threshold visits and/or
procedures and, where relevant, the final certified costs of construction
approved by the department. An appeal may be submitted pursuant to this
paragraph at any time throughout the rate period. Any modified rate certified
or approved pursuant to this paragraph shall be effective on the date the new
service or program is implemented or, in the case of capital renovation,
expansion or replacement, on the date the project is completed and in
use.
(e) Upon receipt of actual
cost data for appeals pursuant to subdivisions (c) and (d) of this section, the
modified rate based on projections will be retroactively revised to reflect
actually incurred costs held to operating cost ceiling limitations and
utilization standards set forth in this Subpart.
(f) Appeals pursuant to subdivision (c) or
(d) of this section for subsequent rate periods must be submitted for each
subsequent period within 120 days of receipt of the commissioner's initial rate
computation sheet for that year.
(g) Appeals to adjustments made as a result
of audits conducted by the Department of Health may be the basis for an
application for rate revision. The specific items of appeal and any material
documentation necessary to support provider's position must be submitted within
30 days of the receipt of the audit.
Notes
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