Bill Text: NY A05245 | 2011-2012 | General Assembly | Introduced
Bill Title: Relates to filing and payment requirements for HMO claims, payment of claims for medical care, HMO electronic remittance advices, health care professional credentialing, and establishes HMO reporting requirements.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2012-09-04 - enacting clause stricken [A05245 Detail]
Download: New_York-2011-A05245-Introduced.html
S T A T E O F N E W Y O R K ________________________________________________________________________ 5245 2011-2012 Regular Sessions I N A S S E M B L Y February 14, 2011 ___________ Introduced by M. of A. P. RIVERA -- read once and referred to the Committee on Insurance AN ACT to amend the social services law, the insurance law, and the public health law, in relation to filing requirements for medical assistance program claims and HMO claims, payment of claims for medical care or services, electronic remittance advices, HMO creden- tialing for health care professionals, and establishing HMO reporting requirements 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 363-a of the social services law, 2 as amended by chapter 474 of the laws of 1996, is amended to read as 3 follows: 4 2. The department of health shall make such regulations, not incon- 5 sistent with law, as may be necessary to implement this title, PROVIDED 6 THAT NO SUCH REGULATIONS SHALL PROVIDE THAT AN OTHERWISE VALID CLAIM FOR 7 MEDICAL CARE, SERVICES OR SUPPLIES PURSUANT TO THE PROVISIONS OF THIS 8 TITLE, SHALL BE DEEMED INVALID AND THUS INELIGIBLE FOR PAYMENT BASED 9 SOLELY UPON THE FAILURE OF SUCH CLAIM TO BE SUBMITTED WITHIN NINETY DAYS 10 OF THE DATE OF SERVICE. 11 S 2. Section 3216 of the insurance law is amended by adding a new 12 subsection (m) to read as follows: 13 (M) NO INSURER SHALL DENY COMPENSATION TO A PARTICIPATING PROVIDER 14 THAT IS NOT LISTED AS A PATIENT'S PRIMARY CARE PHYSICIAN, BUT HAS 15 RENDERED MEDICAL CARE, SERVICES OR SUPPLIES TO AN INSURED. 16 S 3. Section 3221 of the insurance law is amended by adding a new 17 subsection (s) to read as follows: 18 (S) NO INSURER SHALL DENY COMPENSATION TO A PARTICIPATING PROVIDER 19 THAT IS NOT LISTED AS A PATIENT'S PRIMARY CARE PHYSICIAN, BUT HAS 20 RENDERED MEDICAL CARE, SERVICES OR SUPPLIES TO AN INSURED. EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD08316-02-1 A. 5245 2 1 S 4. Section 4303 of the insurance law is amended by adding a new 2 subsection (hh) to read as follows: 3 (HH) NO HOSPITAL SERVICE CORPORATION, HEALTH SERVICE CORPORATION, 4 MEDICAL EXPENSE INDEMNITY CORPORATION, OR OTHER INSURER WHICH PROVIDES 5 COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE SHALL DENY COMPENSATION 6 TO A PARTICIPATING PROVIDER THAT IS NOT LISTED AS A PATIENT'S PRIMARY 7 CARE PHYSICIAN, BUT HAS RENDERED MEDICAL CARE, SERVICES OR SUPPLIES TO 8 AN INSURED. 9 S 5. Subdivision 1 of section 2807-p of the public health law is 10 amended by adding a new paragraph (e) to read as follows: 11 (E) NOTWITHSTANDING ANY OTHER PROVISION OF THIS ARTICLE, IF A FACILITY 12 HAS MADE A GOOD FAITH EFFORT TO COMPLY WITH THE REPORTING REQUIREMENTS 13 SET FORTH IN THIS SECTION, AND FAILS TO SUBMIT SUCH REPORTS OR DATA BY 14 THE ESTABLISHED DEADLINE, SUCH FACILITY SHALL NOT BE SUBJECT TO FINAN- 15 CIAL PENALTY, INCLUDING A DELAY OR DISQUALIFICATION OF FINANCIAL 16 DISTRIBUTIONS, BASED SOLELY UPON SUCH FAILURE TO SUBMIT SUCH REPORTS OR 17 DATA. 18 S 6. The public health law is amended by adding a new section 4408-b 19 to read as follows: 20 S 4408-B. ELECTRONIC REMITTANCE ADVICES. NOTWITHSTANDING ANY OTHER 21 PROVISION OF THIS ARTICLE, UPON RECEIVING AN ELECTRONIC CLAIM FOR COVER- 22 AGE OF A PROCEDURE, TREATMENT, SUPPLY OR SERVICE, OR ANY INFORMATION 23 PERTAINING TO SUCH CLAIM VIA ELECTRONIC METHOD, A HEALTH MAINTENANCE 24 ORGANIZATION LICENSED PURSUANT TO ARTICLE FORTY-THREE OF THE INSURANCE 25 LAW OR CERTIFIED PURSUANT TO THIS ARTICLE, SHALL PROVIDE ELECTRONIC 26 REMITTANCE ADVICES TO THE ENROLLEE, THE HEALTH CARE PROVIDER AND TO ANY 27 NECESSARY PARTIES INVOLVED WITH SUCH CLAIM. FOR THE PURPOSES OF THIS 28 SECTION, "ELECTRONIC REMITTANCE ADVICE" SHALL MEAN AN ELECTRONIC VERSION 29 OF SUCH INFORMATION, AS DESCRIBED IN SECTION FOUR THOUSAND FOUR HUNDRED 30 EIGHT OF THIS ARTICLE, AND AN EXPLANATION OF ALL DETAILS CONCERNING A 31 HEALTH MAINTENANCE ORGANIZATION'S PAYMENT OR DENIAL OF A CLAIM. 32 S 7. Subdivision 1 of section 4406-d of the public health law is 33 amended by adding a new paragraph (c) to read as follows: 34 (C) IF THE COMPLETED APPLICATION OF A HEALTH CARE PROFESSIONAL WHO IS: 35 (I) IN COMPLIANCE WITH THE PROVISIONS OF ARTICLE ONE HUNDRED THIRTY-ONE 36 OF THE EDUCATION LAW, AND (II) IN COMPLIANCE AND IN GOOD STANDING WITH 37 ELIGIBILITY REQUIREMENTS SET FORTH BY THE MEDICAL ASSISTANCE PROGRAM 38 CONCERNING A HEALTH CARE PROFESSIONAL'S PARTICIPATION AS A MEDICAL 39 ASSISTANCE PROVIDER, THE HEALTH CARE PROFESSIONAL SHALL BE ALLOWED TO 40 PROVIDE MEDICAL CARE OR SERVICE AND SUBMIT CLAIMS REGARDING SUCH MEDICAL 41 CARE OR SERVICE PROVIDED TO ENROLLEES PARTICIPATING IN THE MEDICAL 42 ASSISTANCE PROGRAM. 43 S 8. Section 2511 of the public health law is amended by adding a new 44 subdivision 21 to read as follows: 45 21. NOTWITHSTANDING ANY OTHER LAW OR AGREEMENT TO THE CONTRARY, IF A 46 HEALTH CARE PROVIDER OR HEALTH CARE CENTER PROVIDES MEDICAL CARE, 47 SERVICES OR SUPPLIES TO AN ENROLLEE OF A HEALTH MAINTENANCE ORGANIZA- 48 TION, SUCH PROVIDER SHALL BE ENTITLED TO SUBMIT A CLAIM TO THE HEALTH 49 MAINTENANCE ORGANIZATION FOR PAYMENT FOR SUCH MEDICAL CARE OR SERVICES 50 AND FOR PAYMENT OF ANY "BUDGET BALANCE ACT" (BBA) OR CHILD HEALTH PLUS 51 (CHIP) SUBSIDY PAYMENT AMOUNTS ENTITLED TO SUCH PROVIDER. IF SUCH CLAIM 52 IS SUBSEQUENTLY DENIED BY THE APPROPRIATE ORGANIZATION, THE PROVIDER 53 SHALL BE ENTITLED TO PAYMENT FOR SUCH MEDICAL CARE OR SERVICES, PROVIDED 54 THAT THE PATIENT WAS AN ACTIVE PARTICIPANT OF A HEALTH INSURANCE PROGRAM 55 FUNDED BY THE DEPARTMENT AND THE MEDICAL CARE OR SERVICES FURNISHED BY 56 SUCH PROVIDER WERE VALID. A. 5245 3 1 S 9. Section 4408 of the public health law is amended by adding two 2 new subdivisions 7 and 8 to read as follows: 3 7. EVERY THIRTY DAYS, A HEALTH MAINTENANCE ORGANIZATION SHALL PROVIDE 4 TO ALL HEALTH CARE PROVIDERS OR HEALTH CARE CENTERS TO WHOM THEIR ENROL- 5 LEES SEEK MEDICAL CARE OR SERVICE, A REPORT CONTAINING AN EXPLANATION OF 6 CHARGES, PAYMENTS AND THE TOTAL NUMBER OF PATIENTS SERVICED UNDER THE 7 FAMILY HEALTH PLUS PLAN, CHILD HEALTH PLUS PLAN, MEDICARE PROGRAM AND 8 MEDICAID PROGRAM. 9 8. ALL HEALTH MAINTENANCE ORGANIZATIONS SHALL PROVIDE TO HEALTH CARE 10 PROVIDERS AND HEALTH CARE CENTERS, AN ELECTRONIC PATIENT ROSTER CONTAIN- 11 ING A LIST OF CURRENT ENROLLEES ELIGIBLE TO SEEK MEDICAL TREATMENT OR 12 SERVICES WITH SUCH HEALTH CARE PROVIDER OR AT SUCH HEALTH CARE CENTER. 13 S 10. This act shall take effect immediately.