Bill Text: NY A03077 | 2019-2020 | General Assembly | Introduced
Bill Title: Relates to certain application and referral forms for health care plans by authorizing the commissioner and superintendent of financial services to adopt regulations for the renewal of credentialing and re-credentialing of newly licensed health care professionals.
Spectrum: Partisan Bill (Democrat 24-0)
Status: (Engrossed - Dead) 2020-01-08 - ordered to third reading cal.129 [A03077 Detail]
Download: New_York-2019-A03077-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 3077 2019-2020 Regular Sessions IN ASSEMBLY January 28, 2019 ___________ Introduced by M. of A. GOTTFRIED, CAHILL, ENGLEBRIGHT, GALEF, JAFFEE, OTIS, STECK, D'URSO -- Multi-Sponsored by -- M. of A. ABBATE, AUBRY, CARROLL, COLTON, COOK, CYMBROWITZ, DINOWITZ, ORTIZ, PAULIN, PERRY, PRETLOW, RAMOS, RIVERA, TITUS -- read once and referred to the Commit- tee on Health AN ACT to amend the public health law and the insurance law, in relation to certain application and referral forms for health care plans 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 425 of the laws of 2016, 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 universal health care profes- 11 sional application [to participate] for participation in the in-network 12 portion of the health care plan's network and shall, within sixty days 13 of receiving a health care professional's completed universal applica- 14 tion to participate in the health care plan's network, notify the health 15 care professional as to: (i) whether he or she is credentialed; or (ii) 16 whether additional time is necessary to make a determination because of 17 a failure of a third party to provide necessary documentation. In such 18 instances where additional time is necessary because of a lack of neces- 19 sary documentation, a health plan shall make every effort to obtain such 20 information as soon as possible and shall make a final determination 21 within twenty-one days of receiving the necessary documentation. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD03362-01-9A. 3077 2 1 (b) If the completed application of a newly-licensed health care 2 professional or a health care professional who has recently relocated to 3 this state from another state and has not previously practiced in this 4 state, who joins a group practice of health care professionals each of 5 whom participates in the in-network portion of a health care plan's 6 network, is neither approved nor declined within sixty days of 7 submission of a completed application pursuant to paragraph (a) of this 8 subdivision, the health care professional shall be deemed "provisionally 9 credentialed" and may participate in the in-network portion of the 10 health care plan's network; provided, however, that a provisionally 11 credentialed physician may not be designated as an enrollee's primary 12 care physician until such time as the physician has been fully creden- 13 tialed. The network participation for a provisionally credentialed 14 health care professional shall begin on the day following the sixtieth 15 day of receipt of the completed application and shall last until the 16 final credentialing determination is made by the health care plan. A 17 health care professional shall only be eligible for provisional creden- 18 tialing if the group practice of health care professionals notifies the 19 health care plan in writing that, should the application ultimately be 20 denied, the health care professional or the group practice: (i) shall 21 refund any payments made by the health care plan for in-network services 22 provided by the provisionally credentialed health care professional that 23 exceed any out-of-network benefits payable under the enrollee's contract 24 with the health care plan; and (ii) shall not pursue reimbursement from 25 the enrollee, except to collect the copayment that otherwise would have 26 been payable had the enrollee received services from a health care 27 professional participating in the in-network portion of a health care 28 plan's network. Interest and penalties pursuant to section three thou- 29 sand two hundred twenty-four-a of the insurance law shall not be 30 assessed based on the denial of a claim submitted during the period when 31 the health care professional was provisionally credentialed; provided, 32 however, that nothing herein shall prevent a health care plan from 33 paying a claim from a health care professional who is provisionally 34 credentialed upon submission of such claim. A health care plan shall not 35 deny, after appeal, a claim for services provided by a provisionally 36 credentialed health care professional solely on the ground that the 37 claim was not timely filed. 38 (c) The commissioner, in consultation with the superintendent of 39 financial services, and representatives of health care plans, hospitals 40 and health care professionals shall adopt by regulation such universal 41 health care professional application for participation form, and a form 42 for the renewal of credentialing which shall be an abbreviated version 43 of the universal application form, for use by health care plans which 44 offer managed care products for the purpose of credentialing and re-cre- 45 dentialing health care professionals who seek to participate in a health 46 care plan's provider network, including credentialing and re-credential- 47 ing health care professionals who are employed or have staff privileges 48 at hospitals or other health care facilities which seek to participate 49 in a provider network. 50 (d) The commissioner, in consultation with the superintendent of 51 financial services, and representatives of health care plans, hospitals 52 and health care professionals shall adopt by regulation a universal 53 health care professional referral form for the purpose of simplifying 54 the process of referral of patients to other health care professionals. 55 (e) The commissioner, in consultation with the superintendent of 56 financial services, and representatives of health care plans, hospitalsA. 3077 3 1 and health care professionals shall revise the universal application, 2 re-credentialing and universal health care professional referral forms 3 as necessary, to conform with industry-wide, national standards of 4 credentialing, re-credentialing and health care referral. 5 (f) In developing the universal health care professional application 6 re-credentialing forms, the commissioner shall ensure that the creden- 7 tialing and re-credentialing requirements for participation in the medi- 8 caid program and the state child health plus program are adequately 9 reflected on the health care professional application and re-credential- 10 ing forms. 11 (g) All the credentialing and re-credentialing forms required for 12 development under this subdivision shall be the only forms that may be 13 used for credentialing and re-credentialing health care professionals by 14 health care plans, hospitals, and other health care facilities. 15 (h) The professional referral form required for development under this 16 subdivision shall be the only form that a health care plan may require a 17 health care professional to use for the purposes of making a profes- 18 sional referral; provided, however, that a health care plan may request 19 additional patient information separately from the professional referral 20 form for the purposes of reviewing such professional referral. 21 § 2. Subsection (a) of section 4803 of the insurance law, as amended 22 by chapter 425 of the laws of 2016, is amended to read as follows: 23 (a) (1) An insurer which offers a managed care product shall, upon 24 request, make available and disclose to health care professionals writ- 25 ten application procedures and minimum qualification requirements which 26 a health care professional must meet in order to be considered by the 27 insurer for participation in the in-network benefits portion of the 28 insurer's network for the managed care product. The insurer shall 29 consult with appropriately qualified health care professionals in devel- 30 oping its qualification requirements for participation in the in-network 31 benefits portion of the insurer's network for the managed care product. 32 An insurer shall complete review of the health care professional's 33 application to participate in the in-network portion of the insurer's 34 network and, within sixty days of receiving a health care professional's 35 completed application to participate in the insurer's network, will 36 notify the health care professional as to: (A) whether he or she is 37 credentialed; or (B) whether additional time is necessary to make a 38 determination because of a failure of a third party to provide necessary 39 documentation. In such instances where additional time is necessary 40 because of a lack of necessary documentation, an insurer shall make 41 every effort to obtain such information as soon as possible and shall 42 make a final determination within twenty-one days of receiving the 43 necessary documentation. The plans shall also implement procedures to 44 permit newly licensed health care professionals to render care and 45 receive payment for care provided to enrollees on a provisional basis 46 during the pendency of the application process of such newly licensed 47 health care professionals. 48 (2) If the completed application of a newly-licensed health care 49 professional or a health care professional who has recently relocated to 50 this state from another state and has not previously practiced in this 51 state, who joins a group practice of health care professionals each of 52 whom participates in the in-network portion of an insurer's network, is 53 neither approved nor declined within sixty days of submission of a 54 completed application pursuant to paragraph one of this subsection, such 55 health care professional shall be deemed "provisionally credentialed" 56 and may participate in the in-network portion of an insurer's network;A. 3077 4 1 provided, however, that a provisionally credentialed physician may not 2 be designated as an insured's primary care physician until such time as 3 the physician has been fully credentialed. The network participation for 4 a provisionally credentialed health care professional shall begin on the 5 day following the sixtieth day of receipt of the completed application 6 and shall last until the final credentialing determination is made by 7 the insurer. A health care professional shall only be eligible for 8 provisional credentialing if the group practice of health care profes- 9 sionals notifies the insurer in writing that, should the application 10 ultimately be denied, the health care professional or the group prac- 11 tice: (A) shall refund any payments made by the insurer for in-network 12 services provided by the provisionally credentialed health care profes- 13 sional that exceed any out-of-network benefits payable under the 14 insured's contract with the insurer; and (B) shall not pursue reimburse- 15 ment from the insured, except to collect the copayment or coinsurance 16 that otherwise would have been payable had the insured received services 17 from a health care professional participating in the in-network portion 18 of an insurer's network. Interest and penalties pursuant to section 19 three thousand two hundred twenty-four-a of this chapter shall not be 20 assessed based on the denial of a claim submitted during the period when 21 the health care professional was provisionally credentialed; provided, 22 however, that nothing herein shall prevent an insurer from paying a 23 claim from a health care professional who is provisionally credentialed 24 upon submission of such claim. An insurer shall not deny, after appeal, 25 a claim for services provided by a provisionally credentialed health 26 care professional solely on the ground that the claim was not timely 27 filed. 28 (3) The superintendent, in consultation with the commissioner of 29 health, and representatives of health care plans, hospitals, and health 30 care professionals shall adopt by regulation a universal health care 31 professional application for participation form, and a form for the 32 renewal of credentialing which shall be an abbreviated version of the 33 universal application form for use by health care plans which offer 34 managed care products for the purpose of credentialing and re-creden- 35 tialing health care professionals who seek to participate in a health 36 care plan's provider network, including credentialing and re-credential- 37 ing health care professionals who are employed or have staff privileges 38 at hospitals or other health care facilities which seek to participate 39 in a provider network. 40 (4) The superintendent, in consultation with the commissioner of 41 health, and representatives of health care plans, hospitals and health 42 care professionals shall adopt by regulation a universal health care 43 professional referral form for the purpose of simplifying the process of 44 referral of patients to other health care professionals. 45 (5) The superintendent, in consultation with the commissioner of 46 health, and representatives of health care plans, hospitals and health 47 care professionals shall revise the universal application, re-creden- 48 tialing and universal health care professional referral forms as neces- 49 sary, to conform with industry-wide, national standards of credential- 50 ing, re-credentialing and health care referral. 51 (6) In developing the universal health care professional application 52 re-credentialing forms, the superintendent shall ensure that the creden- 53 tialing and re-credentialing requirements for participation in the medi- 54 caid program and the state child health plus program are adequately 55 reflected on the health care professional application and re-credential- 56 ing forms.A. 3077 5 1 (7) The credentialing and re-credentialing forms required for develop- 2 ment under this subsection shall be the only forms that may be used for 3 credentialing and re-credentialing health care professionals by insur- 4 ers, hospitals and other health care facilities. 5 (8) The professional referral form required for development under this 6 subsection shall be the only form that an insurer may require a health 7 care professional to use for the purposes of making a professional 8 referral; provided, however, that an insurer may request additional 9 patient information separately from the professional referral form for 10 the purposes of reviewing such professional referral. 11 § 3. This act shall take effect on the one hundred eightieth day after 12 it shall have become a law.
