Bill Text: NY S06281 | 2013-2014 | General Assembly | Introduced
Bill Title: Requires, for purposes of utilization review and external appeals, clinical peer reviewers to be licensed, registered or certified in this state and to be in the same specialty as the health care provider being reviewed.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2014-01-09 - REFERRED TO INSURANCE [S06281 Detail]
Download: New_York-2013-S06281-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
6281
I N S E N A T E
January 9, 2014
___________
Introduced by Sen. DeFRANCISCO -- read twice and ordered printed, and
when printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law and the public health law, in relation
to the definitions of "clinical peer reviewer" for the purposes of
utilization review and external appeal
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Subsection (b) of section 4900 of the insurance law, as
2 amended by chapter 586 of the laws of 1998, is amended to read as
3 follows:
4 (b) "Clinical peer reviewer" means:
5 (1) for purposes of title one of this article:
6 (A) a physician who possesses a current and valid non-restricted
7 license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE
8 OF THE EDUCATION LAW; or
9 (B) a health care professional other than a licensed physician who:
10 (i) where applicable, possesses a current and valid non-restricted
11 license, certificate or registration [or, where no provision for a
12 license, certificate or registration exists, is credentialed by the
13 national accrediting body appropriate to the profession] ISSUED PURSUANT
14 TO TITLE EIGHT OF THE EDUCATION LAW; and
15 (ii) is in the same profession and same or similar specialty as the
16 health care provider who typically manages the medical condition or
17 disease or provides the health care service or treatment under review;
18 and
19 (2) for purposes of title two of this article:
20 (A) a physician who:
21 (i) possesses a current and valid non-restricted license to practice
22 medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION
23 LAW;
24 (ii) where applicable, is board certified or board eligible in the
25 same or similar specialty as the health care provider who typically
26 manages the medical condition or disease or provides the health care
27 service or treatment under appeal;
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD13479-01-4
S. 6281 2
1 (iii) has been practicing in such area of specialty for a period of at
2 least five years; and
3 (iv) is knowledgeable about the health care service or treatment under
4 appeal; or
5 (B) a health care professional other than a licensed physician who:
6 (i) where applicable, possesses a current and valid non-restricted
7 license, certificate or registration ISSUED PURSUANT TO TITLE EIGHT OF
8 THE EDUCATION LAW;
9 (ii) [where applicable, is credentialed by the national accrediting
10 body appropriate to the profession in the same profession and same or
11 similar specialty as the health care provider who typically manages the
12 medical condition or disease or provides the health care service or
13 treatment under appeal;
14 (iii)] has been practicing in such area of specialty for a period of
15 at least five years;
16 [(iv)] (III) is knowledgeable about the health care service or treat-
17 ment under appeal; and
18 [(v)] (IV) where applicable to such health care professional's scope
19 of practice, is clinically supported by a physician who possesses a
20 current and valid non-restricted license to practice medicine PURSUANT
21 TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW.
22 (3) Nothing [herein] IN THIS ARTICLE shall be construed to change any
23 statutorily-defined scope of practice.
24 S 2. Subdivision 2 of section 4900 of the public health law, as
25 amended by chapter 586 of the laws of 1998, is amended to read as
26 follows:
27 2. "Clinical peer reviewer" means:
28 (a) for purposes of title one of this article:
29 (i) a physician who possesses a current and valid non-restricted
30 license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE
31 OF THE EDUCATION LAW; or
32 (ii) a health care professional other than a licensed physician who:
33 (A) where applicable, possesses a current and valid non-restricted
34 license, certificate or registration [or, where no provision for a
35 license, certificate or registration exists, is credentialed by the
36 national accrediting body appropriate to the profession] ISSUED PURSUANT
37 TO TITLE EIGHT OF THE EDUCATION LAW; and
38 (B) is in the same profession and same or similar specialty as the
39 health care provider who typically manages the medical condition or
40 disease or provides the health care service or treatment under review;
41 and
42 (b) for purposes of title two of this article:
43 (i) a physician who:
44 (A) possesses a current and valid non-restricted license to practice
45 medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION
46 LAW;
47 (B) where applicable, is board certified or board eligible in the same
48 or similar specialty as the health care provider who typically manages
49 the medical condition or disease or provides the health care service or
50 treatment under appeal;
51 (C) has been practicing in such area of specialty for a period of at
52 least five years; and
53 (D) is knowledgeable about the health care service or treatment under
54 appeal; or
55 (ii) a health care professional other than a licensed physician who:
S. 6281 3
1 (A) where applicable, possesses a current and valid non-restricted
2 license, certificate or registration ISSUED PURSUANT TO TITLE EIGHT OF
3 THE EDUCATION LAW;
4 (B) [where applicable, is credentialed by the national accrediting
5 body appropriate to the profession in the same profession and same or
6 similar specialty as the health care provider who typically manages the
7 medical condition or disease or provides the health care service or
8 treatment under appeal;
9 (C)] has been practicing in such area of specialty for a period of at
10 least five years;
11 [(D)] (C) is knowledgeable about the health care service or treatment
12 under appeal; and
13 [(E)] (D) where applicable to such health care professional's scope of
14 practice, is clinically supported by a physician who possesses a current
15 and valid non-restricted license to practice medicine PURSUANT TO ARTI-
16 CLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW.
17 (c) Nothing [herein] IN THIS ARTICLE shall be construed to change any
18 statutorily-defined scope of practice.
19 S 3. This act shall take effect on the one hundred twentieth day after
20 it shall have become a law.
