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) 2019-03-26 - REFERRED TO HEALTH [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.
                                                                   LBD03362-01-9

        A. 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,  hospitals

        A. 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.
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