Bill Text: NY A08898 | 2011-2012 | General Assembly | Introduced

---

Bill Title: Requires insurance companies to supply providers with written confirmation of oral approval for services upon an insured.

Spectrum: Partisan Bill (Democrat 12-0)

Status: (Introduced - Dead) 2012-01-04 - referred to insurance [A08898 Detail]

Download: New_York-2011-A08898-Introduced.html

---

                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                         8898
                                 I N  A S S E M B L Y
                                      (PREFILED)
                                    January 4, 2012
                                      ___________
       Introduced  by M. of A. QUART -- read once and referred to the Committee
         on Insurance
       AN ACT to amend the insurance law and the public health law, in relation
         to pre-authorization of care
         THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
       BLY, DO ENACT AS FOLLOWS:
    1    Section  1.    Subsection (e) of section 4905 of the insurance law, as
    2  added by chapter 705 of the laws of 1996, is amended to read as follows:
    3    (e) If a health care service has been  specifically  preauthorized  or
    4  approved  for  an  insured  by a utilization review agent, a utilization
    5  review agent shall not pursuant to retrospective review revise or modify
    6  the specific standards, criteria or procedures used for the  utilization
    7  review  for procedures, treatment and services delivered to the insured,
    8  during the same course of treatment.
    9    (1) WHENEVER A UTILIZATION REVIEW AGENT MAKES A VERBAL  REPRESENTATION
   10  REGARDING  PREAUTHORIZATION  OR  APPROVAL,  THE UTILIZATION REVIEW AGENT
   11  SHALL IMMEDIATELY THEREAFTER SUPPLY THE PROVIDER WITH A WRITTEN  CONFIR-
   12  MATION OF THE APPROVAL BY EITHER:
   13    (I)  SENDING  A  COPY  OF  SUCH APPROVAL THROUGH ELECTRONIC MAIL TO AN
   14  ADDRESS SPECIFIED BY THE PROVIDER;
   15    (II) SENDING A COPY OF SUCH APPROVAL THROUGH FACSIMILE TRANSMISSION TO
   16  A NUMBER SPECIFIED BY THE PROVIDER; OR
   17    (III) POSTING A COPY OF SUCH APPROVAL ON A WEBSITE ACCESSIBLE  TO  THE
   18  PROVIDER  SO  THAT  THE PROVIDER MAY IMMEDIATELY PRINT AND RETAIN A HARD
   19  COPY.
   20    (2) ABSENT A SHOWING OF MISREPRESENTATION ON BEHALF OF THE PROVIDER OR
   21  THE INSURED, A COPY OF THE APPROVAL REQUIRED PURSUANT TO  PARAGRAPH  ONE
   22  OF  THIS  SUBSECTION  SHALL  BE  PRIMA  FACIE EVIDENCE THAT THE SERVICES
   23  PERFORMED BY THE PROVIDER WERE  MEDICALLY  NECESSARY  COVERED  SERVICES.
   24  SUCH  SERVICES  SHALL  NOT  THEREAFTER  BE  DENIED OR LIMITED, NOR SHALL
   25  REIMBURSEMENT FOR SUCH  SERVICES  BE  DENIED  OR  LIMITED.  WHEN  ACTUAL
   26  SERVICES  RENDERED  DIFFER FROM THOSE SPECIFIC SERVICES PREAUTHORIZED OR
   27  APPROVED DUE TO A RAPID CHANGE IN PATIENT NEEDS, SUCH SERVICES SHALL  BE
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD07477-01-1
       A. 8898                             2
    1  PRESUMPTIVELY APPROVED BUT MAY BE DENIED ON A RETROSPECTIVE REVIEW AFTER
    2  PAYMENT IF SUCH SERVICES ARE DETERMINED NOT TO BE MEDICALLY NECESSARY.
    3    S  2. Subdivision 5 of section 4905 of the public health law, as added
    4  by chapter 705 of the laws of 1996, is amended to read as follows:
    5    5. If a health care service has been  specifically  pre-authorized  or
    6  approved  for  an  enrollee by a utilization review agent, a utilization
    7  review agent shall not, pursuant  to  retrospective  review,  revise  or
    8  modify  the  specific  standards,  criteria  or  procedures used for the
    9  utilization review for procedures, treatment and services  delivered  to
   10  the enrollee during the same course of treatment.
   11    (A)  WHENEVER A UTILIZATION REVIEW AGENT MAKES A VERBAL REPRESENTATION
   12  REGARDING PREAUTHORIZATION OR APPROVAL,  THE  UTILIZATION  REVIEW  AGENT
   13  SHALL  IMMEDIATELY THEREAFTER SUPPLY THE PROVIDER WITH A WRITTEN CONFIR-
   14  MATION OF THE APPROVAL BY EITHER:
   15    (I) SENDING A COPY OF SUCH APPROVAL  THROUGH  ELECTRONIC  MAIL  TO  AN
   16  ADDRESS SPECIFIED BY THE PROVIDER;
   17    (II) SENDING A COPY OF SUCH APPROVAL THROUGH FACSIMILE TRANSMISSION TO
   18  A NUMBER SPECIFIED BY THE PROVIDER; OR
   19    (III)  POSTING  A COPY OF SUCH APPROVAL ON A WEBSITE ACCESSIBLE TO THE
   20  PROVIDER SO THAT THE PROVIDER MAY IMMEDIATELY PRINT AND  RETAIN  A  HARD
   21  COPY.
   22    (B) ABSENT A SHOWING OF MISREPRESENTATION ON BEHALF OF THE PROVIDER OR
   23  THE  ENROLLEE, A COPY OF THE APPROVAL REQUIRED PURSUANT TO PARAGRAPH (A)
   24  OF THIS SUBDIVISION SHALL BE PRIMA  FACIE  EVIDENCE  THAT  THE  SERVICES
   25  PERFORMED  BY  THE  PROVIDER  WERE MEDICALLY NECESSARY COVERED SERVICES.
   26  SUCH SERVICES SHALL NOT THEREAFTER  BE  DENIED  OR  LIMITED,  NOR  SHALL
   27  REIMBURSEMENT  FOR  SUCH  SERVICES  BE  DENIED  OR  LIMITED. WHEN ACTUAL
   28  SERVICES RENDERED DIFFER FROM THOSE SPECIFIC SERVICES  PREAUTHORIZED  OR
   29  APPROVED  DUE TO A RAPID CHANGE IN PATIENT NEEDS, SUCH SERVICES SHALL BE
   30  PRESUMPTIVELY APPROVED BUT MAY BE DENIED ON RETROSPECTIVE  REVIEW  AFTER
   31  PAYMENT IF SUCH SERVICES ARE DETERMINED NOT TO BE MEDICALLY NECESSARY.
   32    S  3.  This  act  shall take effect on the sixtieth day after it shall
   33  have become a law.