Bill Text: NY A00501 | 2015-2016 | General Assembly | Amended
Bill Title: Requires health care plans and insurers to provide expedited review of applications of health care professionals who are joining a group practice.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2016-06-16 - substituted by s2545d [A00501 Detail]
Download: New_York-2015-A00501-Amended.html
STATE OF NEW YORK ________________________________________________________________________ 501--E Cal. No. 355 2015-2016 Regular Sessions IN ASSEMBLY (Prefiled) January 7, 2015 ___________ Introduced by M. of A. CUSICK, ABINANTI -- read once and referred to the Committee on Health -- reported from committee, advanced to a third reading, amended and ordered reprinted, retaining its place on the order of third reading -- again amended on third reading, ordered reprinted, retaining its place on the order of third reading -- recom- mitted to the Committee on Health in accordance with Assembly Rule 3, sec. 2 -- reported from committee, advanced to a third reading, amended and ordered reprinted, retaining its place on the order of third reading -- again amended on third reading, ordered reprinted, retaining its place on the order of third reading -- again amended on third reading, ordered reprinted, retaining its place on the order of third reading AN ACT to amend the public health law and the insurance law, in relation to requiring health care plans and insurers to provide expedited review of applications of health care professionals who are joining a group practice and grant provisional credentials to such professionals The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subdivision 1 of section 4406-d of the public health law, 2 as amended by chapter 237 of the laws of 2009, is amended to read as 3 follows: 4 1. (a) A health care plan shall, upon request, make available and 5 disclose to health care professionals written application procedures and 6 minimum qualification requirements which a health care professional must 7 meet in order to be considered by the health care plan. The plan shall 8 consult with appropriately qualified health care professionals in devel- 9 oping its qualification requirements. A health care plan shall complete 10 review of the health care professional's application to participate in 11 the in-network portion of the health care plan's network and shall, 12 within [ninety] sixty days of receiving a health care professional's EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD01643-14-6A. 501--E 2 1 completed application to participate in the health care plan's network, 2 notify the health care professional as to: (i) whether he or she is 3 credentialed; or (ii) whether additional time is necessary to make a 4 determination [in spite of the health care plan's best efforts or] 5 because of a failure of a third party to provide necessary documenta- 6 tion[, or non-routine or unusual circumstances require additional time7for review]. In such instances where additional time is necessary 8 because of a lack of necessary documentation, a health plan shall make 9 every effort to obtain such information as soon as possible and shall 10 make a final determination within twenty-one days of receiving the 11 necessary documentation. 12 (b) If the completed application of a newly-licensed health care 13 professional or a health care professional who has recently relocated to 14 this state from another state and has not previously practiced in this 15 state, who joins a group practice of health care professionals each of 16 whom participates in the in-network portion of a health care plan's 17 network, is neither approved nor declined within [ninety] sixty days of 18 submission of a completed application pursuant to paragraph (a) of this 19 subdivision, the health care professional shall be deemed "provisionally 20 credentialed" and may participate in the in-network portion of the 21 health care plan's network; provided, however, that a provisionally 22 credentialed physician may not be designated as an enrollee's primary 23 care physician until such time as the physician has been fully creden- 24 tialed. The network participation for a provisionally credentialed 25 health care professional shall begin on the day following the [nineti-26eth] sixtieth day of receipt of the completed application and shall last 27 until the final credentialing determination is made by the health care 28 plan. A health care professional shall only be eligible for provisional 29 credentialing if the group practice of health care professionals noti- 30 fies the health care plan in writing that, should the application ulti- 31 mately be denied, the health care professional or the group practice: 32 (i) shall refund any payments made by the health care plan for in-net- 33 work services provided by the provisionally credentialed health care 34 professional that exceed any out-of-network benefits payable under the 35 enrollee's contract with the health care plan; and (ii) shall not pursue 36 reimbursement from the enrollee, except to collect the copayment that 37 otherwise would have been payable had the enrollee received services 38 from a health care professional participating in the in-network portion 39 of a health care plan's network. Interest and penalties pursuant to 40 section three thousand two hundred twenty-four-a of the insurance law 41 shall not be assessed based on the denial of a claim submitted during 42 the period when the health care professional was provisionally creden- 43 tialed; provided, however, that nothing herein shall prevent a health 44 care plan from paying a claim from a health care professional who is 45 provisionally credentialed upon submission of such claim. A health care 46 plan shall not deny, after appeal, a claim for services provided by a 47 provisionally credentialed health care professional solely on the ground 48 that the claim was not timely filed. 49 § 2. Subsection (a) of section 4803 of the insurance law, as amended 50 by chapter 237 of the laws of 2009, is amended to read as follows: 51 (a) (1) An insurer which offers a managed care product shall, upon 52 request, make available and disclose to health care professionals writ- 53 ten application procedures and minimum qualification requirements which 54 a health care professional must meet in order to be considered by the 55 insurer for participation in the in-network benefits portion of the 56 insurer's network for the managed care product. The insurer shallA. 501--E 3 1 consult with appropriately qualified health care professionals in devel- 2 oping its qualification requirements for participation in the in-network 3 benefits portion of the insurer's network for the managed care product. 4 An insurer shall complete review of the health care professional's 5 application to participate in the in-network portion of the insurer's 6 network and, within [ninety] sixty days of receiving a health care 7 professional's completed application to participate in the insurer's 8 network, will notify the health care professional as to: (A) whether he 9 or she is credentialed; or (B) whether additional time is necessary to 10 make a determination [in spite of the insurer's best efforts or] because 11 of a failure of a third party to provide necessary documentation[, or12non-routine or unusual circumstances require additional time for13review]. In such instances where additional time is necessary because 14 of a lack of necessary documentation, an insurer shall make every effort 15 to obtain such information as soon as possible and shall make a final 16 determination within twenty-one days of receiving the necessary documen- 17 tation. 18 (2) If the completed application of a newly-licensed health care 19 professional or a health care professional who has recently relocated to 20 this state from another state and has not previously practiced in this 21 state, who joins a group practice of health care professionals each of 22 whom participates in the in-network portion of an insurer's network, is 23 neither approved nor declined within [ninety] sixty days of submission 24 of a completed application pursuant to paragraph one of this subsection, 25 such health care professional shall be deemed "provisionally creden- 26 tialed" and may participate in the in-network portion of an insurer's 27 network; provided, however, that a provisionally credentialed physician 28 may not be designated as an insured's primary care physician until such 29 time as the physician has been fully credentialed. The network partic- 30 ipation for a provisionally credentialed health care professional shall 31 begin on the day following the [ninetieth] sixtieth day of receipt of 32 the completed application and shall last until the final credentialing 33 determination is made by the insurer. A health care professional shall 34 only be eligible for provisional credentialing if the group practice of 35 health care professionals notifies the insurer in writing that, should 36 the application ultimately be denied, the health care professional or 37 the group practice: (A) shall refund any payments made by the insurer 38 for in-network services provided by the provisionally credentialed 39 health care professional that exceed any out-of-network benefits payable 40 under the insured's contract with the insurer; and (B) shall not pursue 41 reimbursement from the insured, except to collect the copayment or coin- 42 surance that otherwise would have been payable had the insured received 43 services from a health care professional participating in the in-network 44 portion of an insurer's network. Interest and penalties pursuant to 45 section three thousand two hundred twenty-four-a of this chapter shall 46 not be assessed based on the denial of a claim submitted during the 47 period when the health care professional was provisionally credentialed; 48 provided, however, that nothing herein shall prevent an insurer from 49 paying a claim from a health care professional who is provisionally 50 credentialed upon submission of such claim. An insurer shall not deny, 51 after appeal, a claim for services provided by a provisionally creden- 52 tialed health care professional solely on the ground that the claim was 53 not timely filed. 54 § 3. This act shall take effect on April 1, 2017 and shall apply to 55 all applications submitted on or after such date.
