Bill Text: NY A09946 | 2011-2012 | General Assembly | Amended
Bill Title: Relates to denial of health insurance claims.
Spectrum: Strong Partisan Bill (Democrat 12-1)
Status: (Passed) 2012-08-01 - signed chap.297 [A09946 Detail]
Download: New_York-2011-A09946-Amended.html
S T A T E O F N E W Y O R K
________________________________________________________________________
9946--B
I N A S S E M B L Y
April 26, 2012
___________
Introduced by M. of A. MORELLE, P. RIVERA, ABINANTI -- read once and
referred to the Committee on Insurance -- reported and referred to the
Committee on Ways and Means -- committee discharged, bill amended,
ordered reprinted as amended and recommitted to said committee --
again reported from said committee with amendments, ordered reprinted
as amended and recommitted to said committee
AN ACT to amend the insurance law and the public health law, in relation
to denial of claims
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Section 3217-b of the insurance law is amended by adding a
2 new subsection (j) to read as follows:
3 (J) (1) AN INSURER SHALL NOT DENY PAYMENT TO A GENERAL HOSPITAL CERTI-
4 FIED PURSUANT TO ARTICLE TWENTY-EIGHT OF THE PUBLIC HEALTH LAW FOR A
5 CLAIM FOR MEDICALLY NECESSARY INPATIENT SERVICES RESULTING FROM AN EMER-
6 GENCY ADMISSION PROVIDED BY A GENERAL HOSPITAL SOLELY ON THE BASIS THAT
7 THE GENERAL HOSPITAL DID NOT TIMELY NOTIFY SUCH INSURER THAT THE
8 SERVICES HAD BEEN PROVIDED.
9 (2) NOTHING IN THIS SUBSECTION SHALL PRECLUDE A GENERAL HOSPITAL AND
10 AN INSURER FROM AGREEING TO REQUIREMENTS FOR TIMELY NOTIFICATION THAT
11 MEDICALLY NECESSARY INPATIENT SERVICES RESULTING FROM AN EMERGENCY
12 ADMISSION HAVE BEEN PROVIDED AND TO REDUCTIONS IN PAYMENT FOR FAILURE TO
13 TIMELY NOTIFY; PROVIDED, HOWEVER THAT: (I) ANY REQUIREMENT FOR TIMELY
14 NOTIFICATION MUST PROVIDE FOR A REASONABLE EXTENSION OF TIMEFRAMES FOR
15 NOTIFICATION FOR EMERGENCY SERVICES PROVIDED ON WEEKENDS OR FEDERAL
16 HOLIDAYS, (II) ANY AGREED TO REDUCTION IN PAYMENT FOR FAILURE TO TIMELY
17 NOTIFY SHALL NOT EXCEED THE LESSER OF TWO THOUSAND DOLLARS OR TWELVE
18 PERCENT OF THE PAYMENT AMOUNT OTHERWISE DUE FOR THE SERVICES PROVIDED,
19 AND (III) ANY AGREED TO REDUCTION IN PAYMENT FOR FAILURE TO TIMELY NOTI-
20 FY SHALL NOT BE IMPOSED IF THE PATIENT'S INSURANCE COVERAGE COULD NOT BE
21 DETERMINED BY THE HOSPITAL AFTER REASONABLE EFFORTS AT THE TIME THE
22 INPATIENT SERVICES WERE PROVIDED.
23 S 2. Section 4325 of the insurance law is amended by adding a new
24 subsection (k) to read as follows:
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD15258-06-2
A. 9946--B 2
1 (K) (1) A CORPORATION ORGANIZED UNDER THIS ARTICLE SHALL NOT DENY
2 PAYMENT TO A GENERAL HOSPITAL CERTIFIED PURSUANT TO ARTICLE TWENTY-EIGHT
3 OF THE PUBLIC HEALTH LAW FOR A CLAIM FOR MEDICALLY NECESSARY INPATIENT
4 SERVICES RESULTING FROM AN EMERGENCY ADMISSION PROVIDED BY A GENERAL
5 HOSPITAL SOLELY ON THE BASIS THAT THE GENERAL HOSPITAL DID NOT TIMELY
6 NOTIFY SUCH INSURER THAT THE SERVICES HAD BEEN PROVIDED.
7 (2) NOTHING IN THIS SUBSECTION SHALL PRECLUDE A GENERAL HOSPITAL AND A
8 CORPORATION FROM AGREEING TO REQUIREMENTS FOR TIMELY NOTIFICATION THAT
9 MEDICALLY NECESSARY INPATIENT SERVICES RESULTING FROM AN EMERGENCY
10 ADMISSION HAVE BEEN PROVIDED AND TO REDUCTIONS IN PAYMENT FOR FAILURE TO
11 TIMELY NOTIFY; PROVIDED, HOWEVER THAT: (I) ANY REQUIREMENT FOR TIMELY
12 NOTIFICATION MUST PROVIDE FOR A REASONABLE EXTENSION OF TIMEFRAMES FOR
13 NOTIFICATION FOR EMERGENCY SERVICES PROVIDED ON WEEKENDS OR FEDERAL
14 HOLIDAYS, (II) ANY AGREED TO REDUCTION IN PAYMENT FOR FAILURE TO TIMELY
15 NOTIFY SHALL NOT EXCEED THE LESSER OF TWO THOUSAND DOLLARS OR TWELVE
16 PERCENT OF THE PAYMENT AMOUNT OTHERWISE DUE FOR THE SERVICES PROVIDED,
17 AND (III) ANY AGREED TO REDUCTION IN PAYMENT SHALL NOT BE IMPOSED IF THE
18 PATIENT'S INSURANCE COVERAGE COULD NOT BE DETERMINED BY THE HOSPITAL
19 AFTER REASONABLE EFFORTS AT THE TIME THE INPATIENT SERVICES WERE
20 PROVIDED.
21 S 3. Section 4406-c of the public health law is amended by adding a
22 new subdivision 8 to read as follows:
23 8. (A) A HEALTH CARE PLAN SHALL NOT DENY PAYMENT TO A GENERAL HOSPITAL
24 CERTIFIED PURSUANT TO ARTICLE TWENTY-EIGHT OF THIS CHAPTER FOR A CLAIM
25 FOR MEDICALLY NECESSARY INPATIENT SERVICES RESULTING FROM AN EMERGENCY
26 ADMISSION PROVIDED BY A GENERAL HOSPITAL SOLELY ON THE BASIS THAT THE
27 GENERAL HOSPITAL DID NOT TIMELY NOTIFY SUCH HEALTH CARE PLAN THAT THE
28 SERVICES HAD BEEN PROVIDED.
29 (B) NOTHING IN THIS SUBDIVISION SHALL PRECLUDE A GENERAL HOSPITAL AND
30 A HEALTH CARE PLAN FROM AGREEING TO REQUIREMENTS FOR TIMELY NOTIFICATION
31 THAT MEDICALLY NECESSARY INPATIENT SERVICES RESULTING FROM AN EMERGENCY
32 ADMISSION HAVE BEEN PROVIDED AND TO REDUCTIONS IN PAYMENT FOR FAILURE TO
33 TIMELY NOTIFY; PROVIDED, HOWEVER THAT: (I) ANY REQUIREMENT FOR TIMELY
34 NOTIFICATION MUST PROVIDE FOR A REASONABLE EXTENSION OF TIMEFRAMES FOR
35 NOTIFICATION FOR EMERGENCY SERVICES PROVIDED ON WEEKENDS OR FEDERAL
36 HOLIDAYS, (II) ANY AGREED TO REDUCTION IN PAYMENT FOR FAILURE TO TIMELY
37 NOTIFY SHALL NOT EXCEED THE LESSER OF TWO THOUSAND DOLLARS OR TWELVE
38 PERCENT OF THE PAYMENT AMOUNT OTHERWISE DUE FOR THE SERVICE PROVIDED,
39 AND (III) ANY AGREED TO REDUCTION IN PAYMENT SHALL NOT BE IMPOSED IF THE
40 PATIENT'S COVERAGE COULD NOT BE DETERMINED BY THE HOSPITAL AFTER REASON-
41 ABLE EFFORTS AT THE TIME THE INPATIENT SERVICES WERE PROVIDED.
42 S 4. Section 3224-a of the insurance law is amended by adding a new
43 subsection (i) to read as follows:
44 (I) EXCEPT WHERE THE PARTIES HAVE DEVELOPED A MUTUALLY AGREED UPON
45 PROCESS FOR THE RECONCILIATION OF CODING DISPUTES THAT INCLUDES A REVIEW
46 OF SUBMITTED MEDICAL RECORDS TO ASCERTAIN THE CORRECT CODING FOR
47 PAYMENT, A GENERAL HOSPITAL CERTIFIED PURSUANT TO ARTICLE TWENTY-EIGHT
48 OF THE PUBLIC HEALTH LAW SHALL, UPON RECEIPT OF PAYMENT OF A CLAIM FOR
49 WHICH PAYMENT HAS BEEN ADJUSTED BASED ON A PARTICULAR CODING TO A
50 PATIENT INCLUDING THE ASSIGNMENT OF DIAGNOSIS AND PROCEDURE, HAVE THE
51 OPPORTUNITY TO SUBMIT THE AFFECTED CLAIM WITH MEDICAL RECORDS SUPPORTING
52 THE HOSPITAL'S INITIAL CODING OF THE CLAIM WITHIN THIRTY DAYS OF RECEIPT
53 OF PAYMENT. UPON RECEIPT OF SUCH MEDICAL RECORDS, AN INSURER OR AN
54 ORGANIZATION OR CORPORATION LICENSED OR CERTIFIED PURSUANT TO ARTICLE
55 FORTY-THREE OR FORTY-SEVEN OF THIS CHAPTER OR ARTICLE FORTY-FOUR OF THE
56 PUBLIC HEALTH LAW SHALL REVIEW SUCH INFORMATION TO ASCERTAIN THE CORRECT
A. 9946--B 3
1 CODING FOR PAYMENT AND PROCESS THE CLAIM IN ACCORDANCE WITH THE TIME-
2 FRAMES SET FORTH IN SUBSECTION (A) OF THIS SECTION. IN THE EVENT THE
3 INSURER, ORGANIZATION, OR CORPORATION PROCESSES THE CLAIM CONSISTENT
4 WITH ITS INITIAL DETERMINATION, SUCH DECISION SHALL BE ACCOMPANIED BY A
5 STATEMENT OF THE INSURER, ORGANIZATION OR CORPORATION SETTING FORTH THE
6 SPECIFIC REASONS WHY THE INITIAL ADJUSTMENT WAS APPROPRIATE. AN INSUR-
7 ER, ORGANIZATION, OR CORPORATION THAT INCREASES THE PAYMENT BASED ON THE
8 INFORMATION SUBMITTED BY THE GENERAL HOSPITAL, BUT FAILS TO DO SO IN
9 ACCORDANCE WITH THE TIMEFRAMES SET FORTH IN SUBSECTION (A) OF THIS
10 SECTION, SHALL PAY TO THE GENERAL HOSPITAL INTEREST ON THE AMOUNT OF
11 SUCH INCREASE AT THE RATE SET BY THE COMMISSIONER OF TAXATION AND
12 FINANCE FOR CORPORATE TAXES PURSUANT TO PARAGRAPH ONE OF SUBDIVISION (E)
13 OF SECTION ONE THOUSAND NINETY-SIX OF THE TAX LAW, TO BE COMPUTED FROM
14 THE END OF THE FORTY-FIVE DAY PERIOD AFTER RESUBMISSION OF THE ADDI-
15 TIONAL MEDICAL RECORD INFORMATION. PROVIDED, HOWEVER, A FAILURE TO REMIT
16 TIMELY PAYMENT SHALL NOT CONSTITUTE A VIOLATION OF THIS SECTION. NEITHER
17 THE INITIAL OR SUBSEQUENT PROCESSING OF THE CLAIM BY THE INSURER, ORGAN-
18 IZATION, OR CORPORATION SHALL BE DEEMED AN ADVERSE DETERMINATION AS
19 DEFINED IN SECTION FOUR THOUSAND NINE HUNDRED OF THIS CHAPTER IF BASED
20 SOLELY ON A CODING DETERMINATION. NOTHING IN THIS SUBSECTION SHALL APPLY
21 TO THOSE INSTANCES IN WHICH THE INSURER OR ORGANIZATION, OR CORPORATION
22 HAS A REASONABLE SUSPICION OF FRAUD OR ABUSE.
23 S 5. This act shall take effect July 1, 2013.
