Bill Text: NY A00879 | 2021-2022 | General Assembly | Introduced
Bill Title: Relates to the definition of a clinical peer reviewer by clarifying that such term shall be applicable for the entire utilization review and external appeal article and means either a physician or a health care professional with certain qualifications.
Spectrum: Partisan Bill (Democrat 10-0)
Status: (Vetoed) 2022-12-30 - tabled [A00879 Detail]
Download: New_York-2021-A00879-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 879 2021-2022 Regular Sessions IN ASSEMBLY (Prefiled) January 6, 2021 ___________ Introduced by M. of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, L. ROSENTHAL, COLTON, ABINANTI -- read once and referred to the Committee on Health AN ACT to amend the public health law and the insurance law, in relation to the definition of clinical peer reviewer The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subdivision 2 of section 4900 of the public health law, as 2 amended by chapter 586 of the laws of 1998, item (B) of subparagraph 3 (ii) of paragraph (a) as amended by chapter 41 of the laws of 2014 and 4 subparagraph (iii) as amended and subparagraph (iv) of paragraph (a) as 5 added by section 42 of subpart A of part BB of chapter 57 of the laws of 6 2019, is amended to read as follows: 7 2. "Clinical peer reviewer" means: 8 (a) [for purposes of title one of this article:9(i) a physician who possesses a current and valid non-restricted10license to practice medicine; or11(ii) a health care professional other than a licensed physician who:12(A) where applicable, possesses a current and valid non-restricted13license, certificate or registration or, where no provision for a14license, certificate or registration exists, is credentialed by the15national accrediting body appropriate to the profession; and16(B) is in the same profession and same or similar specialty as the17health care provider who typically manages the medical condition or18disease or provides the health care service or treatment under review;19or20(iii) for purposes of a determination involving substance use disorder21treatment:22(A) a physician who possesses a current and valid non-restricted23license to practice medicine and who specializes in behavioral healthEXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD00261-01-1A. 879 2 1and has experience in the delivery of substance use disorder courses of2treatment; or3(B) a health care professional other than a licensed physician who4specializes in behavioral health and has experience in the delivery of5substance use disorder courses of treatment and, where applicable,6possesses a current and valid non-restricted license, certificate or7registration or, where no provision for a license, certificate or regis-8tration exists, is credentialed by the national accrediting body appro-9priate to the profession; or10(iv) for purposes of a determination involving treatment for a mental11health condition:12(A) a physician who possesses a current and valid non-restricted13license to practice medicine and who specializes in behavioral health14and has experience in the delivery of mental health courses of treat-15ment; or16(B) a health care professional other than a licensed physician who17specializes in behavioral health and has experience in the delivery of a18mental health courses of treatment and, where applicable, possesses a19current and valid non-restricted license, certificate, or registration20or, where no provision for a license, certificate or registration21exists, is credentialed by the national accrediting body appropriate to22the profession; and23(b) for purposes of title two of this article:24(i)] a physician who: 25 [(A)] (i) possesses a current and valid non-restricted license to 26 practice medicine under article one hundred thirty-one of the education 27 law; 28 [(B)] (ii) where applicable, is board certified or board eligible in 29 the same or similar specialty as the health care provider who typically 30 manages the medical condition or disease or provides the health care 31 service or treatment under review or appeal; 32 [(C)] (iii) has been practicing in such area of specialty for a period 33 of at least five years; [and] 34 (iv) for purposes of a determination involving substance use disorder 35 treatment, possesses a current and valid non-restricted license to prac- 36 tice medicine and specializes in behavioral health and has experience in 37 the delivery of substance use disorder courses of treatment; 38 (v) for purposes of a determination involving treatment for a mental 39 health condition, possesses a current and valid non-restricted license 40 to practice medicine and who specializes in behavioral health and has 41 experience in the delivery of mental health courses of treatment; and 42 [(D)] (vi) is knowledgeable about the health care service or treatment 43 under review or appeal; or 44 [(ii)] (b) a health care professional other than a licensed physician 45 who possesses a current and valid non-restricted license or certif- 46 ication under title eight of the education law: 47 [(A)] (i) where applicable, possesses a current and valid non-res- 48 tricted license, certificate or registration; 49 [(B)] (ii) where applicable, is credentialed by the national accredit- 50 ing body appropriate to the profession in the same profession and same 51 or similar specialty as the health care provider who typically manages 52 the medical condition or disease or provides the health care service or 53 treatment under review or appeal; 54 [(C)] (iii) has been practicing in such area of specialty for a period 55 of at least five years;A. 879 3 1 [(D)] (iv) is knowledgeable about the health care service or treatment 2 under review or appeal; [and] 3 (v) for purposes of a determination involving substance use disorder, 4 specializes in behavioral health and has experience in the delivery of 5 substance use disorder courses of treatment and, where applicable, 6 possesses a current and valid non-restricted license, certificate or 7 registration or, where no provision for a license, certificate or regis- 8 tration exists, is credentialed by the national accrediting body appro- 9 priate to the profession; 10 (vi) for purposes of a determination involving treatment for a mental 11 health condition, specializes in behavioral health and has experience in 12 the delivery of mental health courses of treatment and, where applica- 13 ble, possesses a current and valid non-restricted license, certificate, 14 or registration or, where no provision for a license, certificate or 15 registration exists, is credentialed by the national accrediting body 16 appropriate to the profession; and 17 [(E)] (vii) where applicable to such health care professional's scope 18 of practice, is clinically supported by a physician who possesses a 19 current and valid non-restricted license to practice medicine. 20 [(c)] Nothing [herein] in this subdivision shall be construed to 21 change any statutorily-defined scope of practice. 22 § 2. Subsection (b) of section 4900 of the insurance law, as amended 23 by chapter 586 of the laws of 1998, item (ii) of subparagraph (B) of 24 paragraph 1 as amended by chapter 41 of the laws of 2014, subparagraph 25 (C) as amended and subparagraph (D) of paragraph 1 as added by section 26 36 of subpart A of part BB of chapter 57 of the laws of 2019, is amended 27 to read as follows: 28 (b) "Clinical peer reviewer" means: 29 (1) [for purposes of title one of this article:30(A) a physician who possesses a current and valid non-restricted31license to practice medicine; or32(B) a health care professional other than a licensed physician who:33(i) where applicable, possesses a current and valid non-restricted34license, certificate or registration or, where no provision for a35license, certificate or registration exists, is credentialed by the36national accrediting body appropriate to the profession; and37(ii) is in the same profession and same or similar specialty as the38health care provider who typically manages the medical condition or39disease or provides the health care service or treatment under review;40or41(C) for purposes of a determination involving substance use disorder42treatment:43(i) a physician who possesses a current and valid non-restricted44license to practice medicine and who specializes in behavioral health45and has experience in the delivery of substance use disorder courses of46treatment; or47(ii) a health care professional other than a licensed physician who48specializes in behavioral health and has experience in the delivery of49substance use disorder courses of treatment and, where applicable,50possesses a current and valid non-restricted license, certificate or51registration or, where no provision for a license, certificate or regis-52tration exists, is credentialed by the national accrediting body appro-53priate to the profession; or54(D) for purposes of a determination involving treatment for a mental55health condition:A. 879 4 1(i) a physician who possesses a current and valid non-restricted2license to practice medicine and who specializes in behavioral health3and has experience in the delivery of mental health courses of treat-4ment; or5(ii) a health care professional other than a licensed physician who6specializes in behavioral health and has experience in the delivery of7mental health courses of treatment and, where applicable, possesses a8current and valid non-restricted license, certificate, or registration9or, where no provision for a license, certificate or registration10exists, is credentialed by the national accrediting body appropriate to11the profession; and12(2) for purposes of title two of this article:13(A)] a physician who: 14 [(i)] (A) possesses a current and valid non-restricted license to 15 practice medicine under article one hundred thirty-one of the education 16 law; 17 [(ii)] (B) where applicable, is board certified or board eligible in 18 the same or similar specialty as the health care provider who typically 19 manages the medical condition or disease or provides the health care 20 service or treatment under review or appeal; 21 [(iii)] (C) has been practicing in such area of specialty for a period 22 of at least five years; [and] 23 (D) for purposes of a determination involving substance use disorder 24 treatment, possesses a current and valid non-restricted license to prac- 25 tice medicine and who specializes in behavioral health and has experi- 26 ence in the delivery of substance use disorder courses of treatment; 27 (E) for purposes of a determination involving treatment for a mental 28 health condition, possesses a current and valid non-restricted license 29 to practice medicine and who specializes in behavioral health and has 30 experience in the delivery of mental health courses of treatment; and 31 [(iv)] (F) is knowledgeable about the health care service or treatment 32 under review or appeal; or 33 [(B)] (2) a health care professional other than a licensed physician 34 who possesses a current and valid non-restricted license or certif- 35 ication under title eight of the education law: 36 [(i)] (A) where applicable, possesses a current and valid non-res- 37 tricted license, certificate or registration; 38 [(ii)] (B) where applicable, is credentialed by the national accredit- 39 ing body appropriate to the profession in the same profession and same 40 or similar specialty as the health care provider who typically manages 41 the medical condition or disease or provides the health care service or 42 treatment under review or appeal; 43 [(iii)] (C) has been practicing in such area of specialty for a period 44 of at least five years; 45 [(iv)] (D) for purposes of a determination involving substance use 46 disorder treatment, specializes in behavioral health and has experience 47 in the delivery of substance use disorder courses of treatment and, 48 where applicable, possesses a current and valid non-restricted license, 49 certificate or registration or, where no provision for a license, 50 certificate or registration exists, is credentialed by the national 51 accrediting body appropriate to the profession; 52 (E) for purposes of a determination involving treatment for a mental 53 health condition, specializes in behavioral health and has experience in 54 the delivery of mental health courses of treatment and, where applica- 55 ble, possesses a current and valid non-restricted license, certificate, 56 or registration or, where no provision for a license, certificate orA. 879 5 1 registration exists, is credentialed by the national accrediting body 2 appropriate to the profession; 3 (F) is knowledgeable about the health care service or treatment under 4 review or appeal; and 5 [(v)] (G) where applicable to such health care professional's scope of 6 practice, is clinically supported by a physician who possesses a current 7 and valid non-restricted license to practice medicine. 8 [(3)] Nothing [herein] in this subdivision shall be construed to 9 change any statutorily-defined scope of practice. 10 § 3. This act shall take effect on the ninetieth day after it shall 11 have become a law.
