Bill Text: NY A02539 | 2017-2018 | 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 11-0)
Status: (Introduced - Dead) 2018-01-03 - ordered to third reading cal.202 [A02539 Detail]
Download: New_York-2017-A02539-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 2539 2017-2018 Regular Sessions IN ASSEMBLY January 20, 2017 ___________ Introduced by M. of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, ROSENTHAL, KAVANAGH, COLTON, JAFFEE, ABINANTI, SEPULVEDA -- 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 and subparagraph (iii) of paragraph (a) 4 as added by chapter 41 of the laws of 2014, is amended to read as 5 follows: 6 2. "Clinical peer reviewer" means: 7 (a) [for purposes of title one of this article:8(i) a physician who possesses a current and valid non-restricted9license to practice medicine; or10(ii) a health care professional other than a licensed physician who:11(A) where applicable, possesses a current and valid non-restricted12license, certificate or registration or, where no provision for a13license, certificate or registration exists, is credentialed by the14national accrediting body appropriate to the profession; and15(B) is in the same profession and same or similar specialty as the16health care provider who typically manages the medical condition or17disease or provides the health care service or treatment under review;18or19(iii) for purposes of a determination involving substance use disorder20treatment:21(A) a physician who possesses a current and valid non-restricted22license to practice medicine and who specializes in behavioral health23and has experience in the delivery of substance use disorder courses of24treatment; orEXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD02208-01-7A. 2539 2 1(B) a health care professional other than a licensed physician who2specializes in behavioral health and has experience in the delivery of3substance use disorder courses of treatment and, where applicable,4possesses a current and valid non-restricted license, certificate or5registration or, where no provision for a license, certificate or regis-6tration exists, is credentialed by the national accrediting body appro-7priate to the profession; and8(b) for purposes of title two of this article:9(i)] a physician who: 10 [(A)] (i) possesses a current and valid non-restricted license to 11 practice medicine under article one hundred thirty-one of the education 12 law; 13 [(B)] (ii) where applicable, is board certified or board eligible in 14 the same or similar specialty as the health care provider who typically 15 manages the medical condition or disease or provides the health care 16 service or treatment under appeal; 17 [(C)] (iii) has been practicing in such area of specialty for a period 18 of at least five years; 19 (iv) for purposes of a determination involving substance use disorder 20 treatment, possesses a current and valid non-restricted license to prac- 21 tice medicine and specializes in behavioral health and has experience in 22 the delivery of substance use disorder courses of treatment; and 23 [(D)] (v) is knowledgeable about the health care service or treatment 24 under review or appeal; or 25 [(ii)] (b) a health care professional other than a licensed physician 26 who possesses a current and valid non-restricted license or certif- 27 ication under title eight of the education law: 28 [(A)] (i) where applicable, possesses a current and valid non-res- 29 tricted license, certificate or registration; 30 [(B)] (ii) where applicable, is credentialed by the national accredit- 31 ing body appropriate to the profession in the same profession and same 32 or similar specialty as the health care provider who typically manages 33 the medical condition or disease or provides the health care service or 34 treatment under review or appeal; 35 [(C)] (iii) has been practicing in such area of specialty for a period 36 of at least five years; 37 [(D)] (iv) is knowledgeable about the health care service or treatment 38 under review or appeal; 39 (v) for purposes of a determination involving substance use disorder, 40 specializes in behavioral health and has experience in the delivery of 41 substance use disorder courses of treatment and, where applicable, 42 possesses a current and valid non-restricted license, certificate or 43 registration or, where no provision for a license, certificate or regis- 44 tration exists, is credentialed by the national accrediting body appro- 45 priate to the profession; and 46 [(E)] (vi) where applicable to such health care professional's scope 47 of practice, is clinically supported by a physician who possesses a 48 current and valid non-restricted license to practice medicine. 49 [(c)] Nothing [herein] in this subdivision shall be construed to 50 change any statutorily-defined scope of practice. 51 § 2. Subsection (b) of section 4900 of the insurance law, as amended 52 by chapter 586 of the laws of 1998, item (ii) of subparagraph (B) of 53 paragraph 1 as amended and subparagraph (C) of paragraph 1 as added by 54 chapter 41 of the laws of 2014, is amended to read as follows: 55 (b) "Clinical peer reviewer" means: 56 (1) [for purposes of title one of this article:A. 2539 3 1(A) a physician who possesses a current and valid non-restricted2license to practice medicine; or3(B) a health care professional other than a licensed physician who:4(i) where applicable, possesses a current and valid non-restricted5license, certificate or registration or, where no provision for a6license, certificate or registration exists, is credentialed by the7national accrediting body appropriate to the profession; and8(ii) is in the same profession and same or similar specialty as the9health care provider who typically manages the medical condition or10disease or provides the health care service or treatment under review;11or12(C) for purposes of a determination involving substance use disorder13treatment:14(i) a physician who possesses a current and valid non-restricted15license to practice medicine and who specializes in behavioral health16and has experience in the delivery of substance use disorder courses of17treatment; or18(ii) a health care professional other than a licensed physician who19specializes in behavioral health and has experience in the delivery of20substance use disorder courses of treatment and, where applicable,21possesses a current and valid non-restricted license, certificate or22registration or, where no provision for a license, certificate or regis-23tration exists, is credentialed by the national accrediting body appro-24priate to the profession; and25(2) for purposes of title two of this article:26(A)] a physician who: 27 [(i)] (A) possesses a current and valid non-restricted license to 28 practice medicine under article one hundred thirty-one of the education 29 law; 30 [(ii)] (B) where applicable, is board certified or board eligible in 31 the same or similar specialty as the health care provider who typically 32 manages the medical condition or disease or provides the health care 33 service or treatment under review or appeal; 34 [(iii)] (C) has been practicing in such area of specialty for a period 35 of at least five years; 36 (D) for purposes of a determination involving substance use disorder 37 treatment, possesses a current and valid non-restricted license to prac- 38 tice medicine and who specializes in behavioral health and has experi- 39 ence in the delivery of substance use disorder courses of treatment; and 40 [(iv)] (E) is knowledgeable about the health care service or treatment 41 under review or appeal; or 42 [(B)] (2) a health care professional other than a licensed physician 43 who possesses a current and valid non-restricted license or certif- 44 ication under title eight of the education law: 45 [(i)] (A) where applicable, possesses a current and valid non-res- 46 tricted license, certificate or registration; 47 [(ii)] (B) where applicable, is credentialed by the national accredit- 48 ing body appropriate to the profession in the same profession and same 49 or similar specialty as the health care provider who typically manages 50 the medical condition or disease or provides the health care service or 51 treatment under review or appeal; 52 [(iii)] (C) has been practicing in such area of specialty for a period 53 of at least five years; 54 [(iv)] (D) for purposes of a determination involving substance use 55 disorder treatment, specializes in behavioral health and has experience 56 in the delivery of substance use disorder courses of treatment and,A. 2539 4 1 where applicable, possesses a current and valid non-restricted license, 2 certificate or registration or, where no provision for a license, 3 certificate or registration exists, is credentialed by the national 4 accrediting body appropriate to the profession; 5 (E) is knowledgeable about the health care service or treatment under 6 review or appeal; and 7 [(v)] (F) where applicable to such health care professional's scope of 8 practice, is clinically supported by a physician who possesses a current 9 and valid non-restricted license to practice medicine. 10 [(3)] Nothing [herein] in this subdivision shall be construed to 11 change any statutorily-defined scope of practice. 12 § 3. This act shall take effect on the ninetieth day after it shall 13 have become a law.
