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
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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;
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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.