N.Y. Comp. Codes R. & Regs. Tit. 10 § 86-4.17 - Appeal process
(a) An
application by a facility for review of a certified or approved rate pursuant
to section
86-4.16
of this Subpart shall be submitted to the bureau for staff review and shall set
forth the basis for the appeal and the issues of fact. Documentation shall
accompany the application, where appropriate, and the department may request
such additional documentation as is necessary for determination of the issues.
The affirmation or revision of the rate based upon such staff review shall be
final unless, within 30 days of its receipt, a hearing before a rate review
officer is requested by registered or certified mail. The request shall contain
a statement of the factual issues to be resolved. The facility may submit
memoranda on legal issues which it deems relevant to the appeal.
(b) Where the rate review officer determines
that there is no actual issue, the request for a hearing shall be denied and
the facility shall be notified of such determination. No administrative appeal
shall be available from this determination. Where the rate review officer
determines that there is a factual issue, a notice of hearing shall be issued
establishing the date, time and place of the hearing and setting forth the
factual issues as determined by such officer. The hearing shall be held in
conformity with the provisions of section 12-a of the Public Health Law and the State
Administrative Procedure Act.
(c)
The recommendation of the rate review officer shall be submitted to the
Commissioner of Health for final approval or disapproval and recertification of
the rate where appropriate.
(d) In
reviewing appeals for revisions to certified or approved rates, the
commissioner may refuse to accept or consider an appeal from a facility:
(1) which is providing an unacceptable level
of care as determined after review by the State Hospital Review and Planning
Council;
(2) which is operated by
management determined by the department to be providing an acceptable level of
care in one of its facilities as determined after review by the State Hospital
Review and Planning Council;
(3)
where it has been determined by the commissioner that the operation is being
conducted by a person or persons not properly established in accordance with
the Public Health Law; or
(4) where
a fine or penalty has been imposed on the facility and such fine or penalty has
not been paid.
(e) If an
appeal or application by a facility affects only the facility's article 43
rate, the facility must appeal or make application to the article 43
corporation for a change or revision in its article 43 rate within the time
periods set forth in this Subpart. If the article 43 corporation recommends
that such appeal or application be granted, it shall forward such
recommendation to the commissioner for determination. If the article 43
corporation denies such appeal or application, the facility may, within 30 days
after receipt of the denial, appeal such determination to the commissioner. The
basis upon which a facility may appeal or make application for a change or
revision in its article 43 rate shall be the same as the basis for an appeal or
application set forth in this Subpart.
(f) If an appeal or application by a facility
for a change or revision in its rate of reimbursement paid by government
agencies and determined pursuant to this Subpart also affects the facility's
approved article 43 rate, the facility shall forward a copy of its appeal or
application to the article 43 corporation at the same time the facility submits
the appeal or application to the commissioner. The article 43 corporation shall
forward any recommendation for a determination of such appeal or application to
the commissioner. Upon the commissioner's determination, the article 43
corporation shall send a copy of such determination to the facility.
Notes
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