All Ambulatory Patient Group (APG) rate appeals submitted by a hospital, freestanding clinics or ambulatory surgery centers require a cover letter signed by the operator or chief executive officer, delineating the specific item(s) of appeal. (Note: Freestanding clinics and ambulatory surgery centers are licensed as D&TCs.)

To be considered for an APG rate-appeal request rate appeals, and the responses to requests for additional information, must be postmarked within the timeframes specified in New York Codes Rules and Regulations (NYCRR) Section 86-8.5. These timeframes start to run on the date the notification is sent to the facility that a new rate posting, or request for additional information, has been uploaded to the Health Commerce System (HCS). Notifications will be sent using the email address maintained by the facility for the HCS. Facilities are responsible for keeping this email address current and checking it for notifications from the Department. The date the notification is sent to the facility is also evidenced in the "Dear Administrator Letter" document that is posted on the HCS and describes the rate update. Please refer to the Rate Notification Process for further information.

• Hardcopy letters of request, with the original signature, should be submitted to the below address. This letter should provide the details of the request.
• Please note that only the original signed letter is required to be hardcopy mailed. All backup documentation can be emailed to the following:

  D&TCs
  Hospitals.

• Name and address for request submission:
  • Monique Grimm
    Director
    Bureau of Hospital and Clinic Rate Setting
    One Commerce Plaza - Room 1430
    99 Washington Avenue
    Albany, New York 12210
• Please note that during the Public Health Emergency the requirement for the original signed hardcopy letter to be physically mailed has been waived. Due to staff at the facility and Department of Health staff working remotely, letters of request are being accepted by email. Depending on the provider type, letters should be emailed to the appropriate email address as provided above.
• Providers will be notified by email that the resolution of the appeal request has been posted on the Health Commerce System (HCS). The email will be sent to the facility contacts that have access to the D&TC Program Applications on the HCS. Please refer to the Rate Notification Process for further information.

D&TCs:

Part 86-8.5 of the New York Codes, Rules and Regulations (NYCRR) sets forth the rules governing appeals for Ambulatory Patient Group rate calculations. In addition, please refer to Part 86-4.16 NYCRR for other appealable rate issues.

1. Supporting Schedules of any pertinent data are to be included with the rate appeal letter of request.
   • Any item of appeal that alters the original cost or statistical data, upon which the rate is based, must meet the same certification requirements as the original document.
   • All rate appeals and supporting documentation pertaining to the request must be submitted to the address above by the applicable deadline to be deemed timely. Applicable deadlines for statewide rate revisions are noted in the release of the "Dear Administrator" letter posted on the Health Commerce System/Healthcare Financial Data Gateway (HCS/HFDG) with each rate publication. For access to the HCS/HFDG, refer to the section for New Article 28 D&TC Freestanding Providers below, item C.
2. Capital rate appeals based on a Certificate of Need (CON) approval must also provide the following information:
   • Copy of the Certificate of Need (CON) approval letter issued by the Division of Health Facility Planning.
   • Copy of the project completion and building occupancy letter issued by the regional office Department of Health after the onsite visit.
   • Completion of the Capital Rate Appeal Form: (Web) - (XLSX) - (PDF)

Hospitals:

Part 86-8.5 of the New York Codes, Rules and Regulations (NYCRR) sets forth the rules governing appeals for Ambulatory Patient Group (APG) rate calculations.

Please refer to Part 86-1.32 of the NYCRR for appealable issues that would pertain to outpatient rates.

The below information is required to establish a Medicaid fee-for-service rate for a new Article 28 Diagnostic & Treatment Center (D&TC) freestanding provider.

1. The provider´s written request (refer to first section for All Rate Appeals) must include a completed New Provider Form.
   • New Freestanding Clinic Form (Web) - (XLSX) - (PDF) which requires the following information:
     1. A copy of the Certificate of Need (CON) approval;
     2. A copy of the approved operating certificate;
     3. Total and Medicaid Fee-for-Service projected visits;
     4. Capital cost data including lease information, if applicable;
     5. Type of Provider (Section 86-4.13 - Groupings).
   • New Freestanding Ambulatory Surgery Center Form (Web) - (XLSX) - (PDF) which requires the following information:
     1. A copy of the Certificate of Need (CON) approval;
     2. Medicaid Fee-for-Service projected visits/procedures.
2. Cost reporting requirements:
   • In accordance with the New York Codes Rules and Regulations (NYCRR) Section 86-4.3, the provider is required to submit a cost report.
   • In accordance with Public Health Law Section 2807 (7-b)(b), a New Provider must elect the period of reporting (calendar year or fiscal July 1 - June 30th). An Election Form (Web) - (PDF) is required to be completed. Once this election is made, it cannot be changed.
3. Providers should establish an account on the Health Commerce System (HCS) and request access to the D&TC Program Applications. Information for that process and contacts for the HCS can be found under the Rate Notification Process.
4. Providers should subscribe to the Department of Health´s APG website to receive a notification when the APG website has been updated. At the time the website is updated, an email is sent to all subscribers advising as such with details describing the updates.
5. New Providers are also advised to contact Provider Enrollment to enroll in NY Medicaid. This enrollment process will establish a Medicaid Provider Number to receive Medicaid payments. In addition, this process will also enable clinic site locations to be established in the eMedNY payment system. Enrollment information can be found here.

For New York State, providers receiving the designation of Federally Qualified Health Center or Rural Health Clinic receive the same FQHC rate methodology and ceilings and are collectively referred to as FQHCs.

FQHCs can apply for an (A) initial rate or (B) a rate change based on a change in its Scope of Services or (C) a capital rate change. The details of the request for a rate change must be provided in a written request (All Rate Appeals section) along with the following:

1. Initial FQHC rate:
   • A request for an initial rate based on actual cost data must be supported by a certified Ambulatory Health Care Facility (AHCF) cost report and all required documentation (Audited Financial Statements, CPA Certification and CEO Certification). Current actual cost data would be available for an existing D&TC that converted to an FQHC and as required, an AHCF Cost Report was submitted for the time period of the conversion.
   • A request for an initial rate based on budgeted costs must include the details on the Initial FQHC Rate: (Web) - (XLSX) - (PDF). If a full year of actual costs are available for the rate year being requested, the actual costs will be used for the rate development versus the budgeted cost submission. Please refer to the first bullet above. See "D" if budgeted data is used for rate development.
   • Documentation from the Health Resources and Services Administration (HRSA) approving the designation and the effective date of the approval.
   • For a newly opened FQHC (not an existing D&TC receiving FQHC designation), please also refer to the New Article 28 D&TC Freestanding Provider section items B through E.
2. Scope of Services:
   • Copy of the New York State Certificate of Need (CON) approval letter or construction notice for the qualifying Scope of Services change and supporting details.
   • Copy of the project completion letter issued by the regional office Department of Health after the onsite visit.
   • Documentation from the Health Resources and Services Administration (HRSA).
   • If a full year of actual data is available, the certified AHCF cost report, with all required documentation (Audited Financial Statements, CPA Certification and CEO Certification), must have been submitted to the Department of Health to be used for rate development. See "D" if budgeted data is used for rate development.
3. Capital rate change:
   • Copy of the New York State Certificate of Need (CON) approval letter or construction notice for the capital change and supporting details.
   • Copy of the project completion letter issued by the regional office Department of Health after the onsite visit.
   • Completion of the Capital Rate Appeal Form: (Web) - (XLSX) - (PDF)
   • If a full year of actual data is available, the certified AHCF cost report, with all required documentation (Audited Financial Statements, CPA Certification and CEO Certification), must have been submitted to the Department of Health to be used for rate development. See "D" if budgeted data is used for rate development.
4. For rate scenarios A, B & C, if a full year of actual data is not available and budgeted data is used for rate development, the budgeted data will be reconciled to actual data at the time the first full year of actual cost data is available. Submission of the actual cost data year report, when available, is required to continue to receive the requested rate change.