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Documents : State Fair Hearing Regulations

18 NYCRR 513.8 - Fair Hearings Involving Requests for Prior Approval for Medical, Dental and Remedial Care (current as of June 27, 2008)

In addition to 18 NYCRR Part 358, 18 NYCRR § 513.8 governs Fair Hearings to review determinations involving requests for prior approval of Medical Assistance (MA) payment for medical, dental and remedial care. This regulation reads as follows:

§ 513.8  Fair hearings

     (a) A recipient may ask for a fair hearing from this department to review a denial or modification of a request or the failure of the Department of Health to make a determination within the time period specified in this Part. The method for asking for the hearing and the procedures for the conduct of the hearing are governed by Part 358 of this Title.

     (b) A fair hearing held pursuant to this section is limited to a review of the following issues:

     (1) whether the requested medical, dental and remedial care, services or supplies are medically necessary and appropriate for the individual recipient's medical needs;

     (2) whether other adequate and less expensive alternatives have been explored and, where appropriate and cost effective, were authorized;

     (3) whether the medical or dental care, services or supplies requested or authorized conform to accepted professional standards;

     (4) whether the Department of Health failed to make a determination within the time period specified in this Part; and

     (5) whether the recipient and the Department of Health complied with the processes and procedures of this Part and Part 358 of this Title.

     (c) A decision after fair hearing may remand the case to the Department of Health if the evidence in the hearing record is not sufficient either to affirm or overturn the determination, or there is reason to believe that a remand would result in a more equitable determination. This may occur when: new and material evidence has been received at the hearing; there has been a material change in law or policy affecting the case; there has been a change in the recipient's condition; or the requested care, services or supplies no longer meet the recipient's needs.


The text of all New York State regulations is available free of charge at the web site of Thompson West - arranged by the New York State Department of State. Click on the following link to conduct a search for any state regulation: http://government.westlaw.com/linkedslice/search/default.asp?RS=GVT1.0&VR=2.0&SP=nycrr-1000


Created: 6/30/2008
Updated: 7/5/2008