The Department of Health applied for a Waiver of Face-to-Face Conference Requirements to allow the provision of telephone conferences (pursuant to 18 NYCRR 358-4.2(i)) as well as a Waiver of the Requirement for the Agency to Appear in Person at the Fair Hearing to enable the social services agency to appear at hearings on papers only (pursuant to 18 NYCRR 358-4.3(c)) for cases related to two Medicaid utilization review programs. By letter dated October 27, 1998, the Office of Administrative Hearings (OAH) approved the requested blanket waivers. This waiver applies to two types of utilization review programs, as described below:
Prospective admission reviews are being conducted by the New York State Quality Review Alliance (NYSQRA), which is a consortium of two review organizations, as part of a two-year inpatient hospital utilization review demonstration, which began April 1, 1998. The purpose of the study is to review Medicaid fee-for-service-inpatient admissions of a randomly selected test group comprising one third of the hospitals in the State to determine appropriateness of payment for inpatient care. More extensive information regarding this demonstration project can be found in Sharon Silversmith's May 12, 1998 memorandum entitled Medicaid Review Demonstration Project NYSHSRO. The remaining two thirds of the State's hospitals will have the hospital utilization reviews conducted by the Island Peer Review Organization (IPRO) on a retrospective basis. Outcomes of both types of reviews may or may not be hearable, and a determination will be made on a case-by-case basis.
For coding purposes, we have devised a new agency field, NQRA, to be placed in the secondary agency position, for requests involving determinations as to eligibility for payment as determined by the NYSQRA review. Future notices will be directed to the client rather than to the physician since requests for hearing must be made either by the client or with the appropriate authorization of the client.
Use of this coding will generate notifications and a copy of the decision to:
Ms. Sandra Silvanic, Vice President, Operations
NYS Quality Review Alliance (NYSQRA)
50 West 23rd Street, 9th Floor
New York, New York 10010
A copy of the decision only will also be forwarded to:
Mr. Gerald Stenson, Principal Medical Care Admin.
NYS Department of Health
Bureau of Hospital and Primary Care Services
Hedley Park Place, Suite 303
433 River Street
Troy, New York 12180
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