Bill Text: NY A02880 | 2019-2020 | General Assembly | Amended
Bill Title: Limits denial of coverage of additional or alternative services or procedures related to health care services for which pre-authorization was granted or did not require pre-authorization.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2019-12-12 - SIGNED CHAP.640 [A02880 Detail]
Download: New_York-2019-A02880-Amended.html
STATE OF NEW YORK ________________________________________________________________________ 2880--B Cal. No. 493 2019-2020 Regular Sessions IN ASSEMBLY January 28, 2019 ___________ Introduced by M. of A. HUNTER -- read once and referred to the Committee on Insurance -- reported and referred to the Committee on Codes -- advanced to a third reading, passed by Assembly and delivered to the Senate, recalled from the Senate, vote reconsidered, bill amended, 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 insurance law, in relation to denial of coverage of additional or related services or procedures related to health care services for which pre-authorization was granted or did not require pre-authorization; and to repeal certain provisions of such law relat- ing thereto The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (c) of section 3238 of the insurance law is 2 REPEALED and a new subsection (c) is added to read as follows: 3 (c)(1) If a health care provider, while providing a service or proce- 4 dure to treat a patient, determines that providing an additional or 5 related service or procedure, such as a service or procedure to address 6 a co-morbid condition, is immediately necessary as part of such treat- 7 ment, and in the clinical judgment of the health care provider it is a 8 medically timely service and it would not be medically advisable to 9 interrupt the provision of care to the patient in order to obtain pre- 10 authorization from a health plan for the additional or related service 11 or procedure, a denial of payment for the additional or related service 12 or procedure due to lack of pre-authorization shall be upheld on appeal 13 only if it is determined that: 14 (i) the additional or related service or procedure is not a covered 15 benefit; EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD04761-07-9A. 2880--B 2 1 (ii) the additional or related service or procedure was not medically 2 necessary pursuant to section four thousand nine hundred four of this 3 chapter or section forty-nine hundred four of the public health law; 4 (iii) the additional or related service or procedure was experimental 5 or investigational pursuant to section four thousand nine hundred four 6 of this chapter or section forty-nine hundred four of the public health 7 law; or 8 (iv) one of the conditions set forth in paragraphs one through six of 9 subsection (a) of this section is met. 10 (2) The provisions of this subsection shall apply to situations in 11 which pre-authorization was required and received for the initial 12 service or procedure. 13 (3) The provisions of this subsection shall apply without regard to 14 whether the current procedural terminology (CPT) code for the additional 15 or related service or procedure is different than the CPT code for the 16 initial service or procedure. 17 § 2. This act shall take effect on the ninetieth day after it shall 18 have become a law.
