N.Y. Comp. Codes R. & Regs. Tit. 10§ 85.1 - Emergency or urgent surgery
(a)
To be a covered benefit under medical assistance for the needy as provided in
section 365-1(5)(a) of the Social Services Law, any emergency or urgent surgery
shall be for alleviation of severe pain or for the immediate diagnosis and/or
treatment of conditions which threaten disability or death if not promptly
diagnosed or treated. No such emergency or urgent surgery requires prior
determination of coverability. In each case, a person designated by the
Commissioner of Health shall determine coverability of this benefit based upon
the documented existence of one or more conditions such as the following:
(1) obstetrical crises and/or
labor;
(2) acute trauma;
(3) reparative or reconstructive surgical
procedures performed within 60 days of acute trauma;
(4) malignancy, confirmed or
suspected;
(5) hemorrhage or threat
of hemorrhage;
(6) serious
infection;
(7) severe
pain;
(8) shock or impending
shock;
(9) decompensated vital
functions or threat to vital functions such as sensorium, respiration,
circulation, excretion and sensory organs;
(10) congenital defects or abnormalities in a
newborn infant best managed by prompt intervention;
(11) any condition the management of which
requires prompt diagnostic procedures necessarily performed on an inpatient
basis such as biopsy and endoscopy; or
(12) any other condition which causes severe
pain or threatens disability or death if not promptly diagnosed or
treated.
(b) The first
three days of inpatient care, services and supplies for persons admitted to
inpatient hospital care under this section shall be deemed a covered benefit
under medical assistance for the needy. To be a covered benefit after the third
day of inpatient care, there shall be a determination of benefit coverability
prior to the end of the third day by a person designated by the Commissioner of
Health. Such initial determination shall be for a specified period of time not
to exceed the 50th percentile of length of stay norms for comparable patients
which have been authorized by the Commissioner Health or the 20th day of stay,
whichever is less. If the stay is for rehabilitation of physical disability as
described in section
85.5(a)
of this Part, such specified period of time shall not exceed the 40th day of
stay. Determination of coverability shall be based upon the existence of one or
more conditions such as those listed in subdivision (a) of this section which
can be treated only on an inpatient hospital basis, as documented in the
patient's medical record. Subsequent to this initial determination of
coverability, extensions of benefit coverability shall be subject to length of
stay limitations of sections
85.5
and
85.7
of this Part.
(c) Determination of
benefit coverability under this section shall be made by a designated physician
or nonphysician under a designated physician's supervision. A determination of
noncoverability shall be made only by a designated physician. If such
determination of noncoverability is made, any care, supplies or services
provided beyond three days shall not be a covered benefit under medical
assistance for the needy.
(d)
Notice of determination shall be given to the patient's surgeon, the hospital
administrator and, if there is a determination of noncoverability, to the
patient. The hospital shall keep any such notification on file, accessible for
review by representatives of the State or of the local social services
district. The patient's surgeon or hospital administrator may, within three
days of the date of such notification, appeal a determination of
noncoverability in writing to the physician or physicians designated by the
commissioner for such purpose. Notification of the decision on appeal shall be
given to the patient's surgeon, the hospital administrator and the patient. If
the determination of noncoverability is affirmed on appeal, any inpatient
hospital care, supplies or services provided beyond three days shall not be a
covered benefit.
(e) If the person
designated by the Commissioner of Health decides in the course of making
determinations of coverability under this section or it is determined from
other sources that a physician, physicians or the hospital are admitting
patients under this section for medical conditions which are not for
alleviation of severe pain or for the immediate diagnosis and/or treatment of
conditions which threaten disability or death if not promptly diagnosed or
treated, the designated person shall give written notification to the
physician(s) and the hospital that if such admissions continue, the initial
three-day period of stay will no longer be deemed a covered benefit. If
patients are thereafter admitted for medical conditions which are not for the
aforesaid purposes, the designated person shall notify the physician(s) and the
hospital that to be a covered benefit, the first three days of inpatient stay
will be subject to a determination of coverability. Such determination of
coverability shall be made prior to the end of the third day of inpatient
hospital stay in accordance with the procedures in subdivisions (a), (b), (c)
and (d) of this section. If there is a determination of non-coverability, any
inpatient hospital care, supplies or services provided shall not be a covered
benefit under medical assistance for the needy.
Notes
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