Updated Medicaid Utilization Review Regulations from NYS Department of Health

Harris Beach PLLC

The New York Department of Health (DOH) adopted regulations effective on September 13, 2023, that revised Medicaid Utilization Review for Medicaid fee-for-service benefits. The regulations were initially published on April 19, 2023, and no comments were received during the review-and-comment period prior to adoption.   

Although some changes were made to Sections 505.2[1] and 506.5[2], the majority of the changes appear in Part 511.[3] Section 511.1[4] now provides that utilization review “evaluates the appropriateness and quality of medical assistance” and “safeguards against unnecessary utilization of care and services.” Utilization reviews will include “post-payment review process to develop and review beneficiary utilization profiles, provider services profiles and exceptions criteria to correct misutilization practice of beneficiaries and providers.” Section 511.1 also provides for “referral to New York’s Office of the Medicaid Inspector General where suspected fraud, waste or abuse are identified in the unnecessary or inappropriate use of care, service or supplies.”

Section 511.2 has been repealed and 511.3 has been renumbered as the new 511.2.[5] The new section 511.2 outlines those Medicaid services that are excluded from the utilization review program. Added to the prior list are: services provided pursuant to a court order; or services provided as a condition of eligibility for any other public program, including, but not limited to public assistance. 

[1] 18 New York Codes, Rules and Regulations § 505.2.

[2] 18 New York Codes, Rules and Regulations § 506.5.

[3] 18 New York Codes, Rules and Regulations Part 511.

[4] 18 New York Codes, Rules and Regulations § 511.1.

[5] 18 New York Codes, Rules and Regulations § 511..2.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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