Bill Text: NY S04335 | 2019-2020 | General Assembly | Introduced


Bill Title: Relates to certain application and referral forms for health care plans by authorizing the commissioner and superintendent of financial services to adopt regulations for the renewal of credentialing and re-credentialing of newly licensed health care professionals.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2019-06-20 - COMMITTED TO RULES [S04335 Detail]

Download: New_York-2019-S04335-Introduced.html


                STATE OF NEW YORK
        ________________________________________________________________________
                                          4335
                               2019-2020 Regular Sessions
                    IN SENATE
                                      March 7, 2019
                                       ___________
        Introduced  by  Sen. SALAZAR -- read twice and ordered printed, and when
          printed to be committed to the Committee 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.
    22    (b) If the completed  application  of  a  newly-licensed  health  care
    23  professional or a health care professional who has recently relocated to
    24  this  state  from another state and has not previously practiced in this
    25  state, who joins a group practice of health care professionals  each  of
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD03362-01-9

        S. 4335                             2
     1  whom  participates  in  the  in-network  portion of a health care plan's
     2  network,  is  neither  approved  nor  declined  within  sixty  days   of
     3  submission  of a completed application pursuant to paragraph (a) of this
     4  subdivision, the health care professional shall be deemed "provisionally
     5  credentialed"  and  may  participate  in  the  in-network portion of the
     6  health care plan's network;  provided,  however,  that  a  provisionally
     7  credentialed  physician  may  not be designated as an enrollee's primary
     8  care physician until such time as the physician has been  fully  creden-
     9  tialed.  The  network  participation  for  a  provisionally credentialed
    10  health care professional shall begin on the day following  the  sixtieth
    11  day  of  receipt  of  the completed application and shall last until the
    12  final credentialing determination is made by the  health  care  plan.  A
    13  health  care professional shall only be eligible for provisional creden-
    14  tialing if the group practice of health care professionals notifies  the
    15  health  care  plan in writing that, should the application ultimately be
    16  denied, the health care professional or the group  practice:  (i)  shall
    17  refund any payments made by the health care plan for in-network services
    18  provided by the provisionally credentialed health care professional that
    19  exceed any out-of-network benefits payable under the enrollee's contract
    20  with  the health care plan; and (ii) shall not pursue reimbursement from
    21  the enrollee, except to collect the copayment that otherwise would  have
    22  been  payable  had  the  enrollee  received  services from a health care
    23  professional participating in the in-network portion of  a  health  care
    24  plan's  network.  Interest and penalties pursuant to section three thou-
    25  sand two hundred  twenty-four-a  of  the  insurance  law  shall  not  be
    26  assessed based on the denial of a claim submitted during the period when
    27  the  health  care professional was provisionally credentialed; provided,
    28  however, that nothing herein shall  prevent  a  health  care  plan  from
    29  paying  a  claim  from  a  health care professional who is provisionally
    30  credentialed upon submission of such claim. A health care plan shall not
    31  deny, after appeal, a claim for services  provided  by  a  provisionally
    32  credentialed  health  care  professional  solely  on the ground that the
    33  claim was not timely filed.
    34    (c) The commissioner,  in  consultation  with  the  superintendent  of
    35  financial  services, and representatives of health care plans, hospitals
    36  and health care professionals shall adopt by regulation  such  universal
    37  health  care professional application for participation form, and a form
    38  for the renewal of credentialing which shall be an  abbreviated  version
    39  of  the  universal  application form, for use by health care plans which
    40  offer managed care products for the purpose of credentialing and re-cre-
    41  dentialing health care professionals who seek to participate in a health
    42  care plan's provider network, including credentialing and re-credential-
    43  ing health care professionals who are employed or have staff  privileges
    44  at  hospitals  or other health care facilities which seek to participate
    45  in a provider network.
    46    (d) The commissioner,  in  consultation  with  the  superintendent  of
    47  financial  services, and representatives of health care plans, hospitals
    48  and health care professionals shall  adopt  by  regulation  a  universal
    49  health  care  professional  referral form for the purpose of simplifying
    50  the process of referral of patients to other health care professionals.
    51    (e) The commissioner,  in  consultation  with  the  superintendent  of
    52  financial  services, and representatives of health care plans, hospitals
    53  and health care professionals shall revise  the  universal  application,
    54  re-credentialing  and  universal health care professional referral forms
    55  as necessary, to  conform  with  industry-wide,  national  standards  of
    56  credentialing, re-credentialing and health care referral.

        S. 4335                             3
     1    (f)  In  developing the universal health care professional application
     2  re-credentialing forms, the commissioner shall ensure that  the  creden-
     3  tialing and re-credentialing requirements for participation in the medi-
     4  caid  program  and  the  state  child health plus program are adequately
     5  reflected on the health care professional application and re-credential-
     6  ing forms.
     7    (g)  All  the  credentialing  and  re-credentialing forms required for
     8  development under this subdivision shall be the only forms that  may  be
     9  used for credentialing and re-credentialing health care professionals by
    10  health care plans, hospitals, and other health care facilities.
    11    (h) The professional referral form required for development under this
    12  subdivision shall be the only form that a health care plan may require a
    13  health  care  professional  to  use for the purposes of making a profes-
    14  sional referral; provided, however, that a health care plan may  request
    15  additional patient information separately from the professional referral
    16  form for the purposes of reviewing such professional referral.
    17    §  2.  Subsection (a) of section 4803 of the insurance law, as amended
    18  by chapter 425 of the laws of 2016, is amended to read as follows:
    19    (a) (1) An insurer which offers a managed  care  product  shall,  upon
    20  request,  make available and disclose to health care professionals writ-
    21  ten application procedures and minimum qualification requirements  which
    22  a  health  care  professional must meet in order to be considered by the
    23  insurer for participation in the  in-network  benefits  portion  of  the
    24  insurer's  network  for  the  managed  care  product.  The insurer shall
    25  consult with appropriately qualified health care professionals in devel-
    26  oping its qualification requirements for participation in the in-network
    27  benefits portion of the insurer's network for the managed care  product.
    28  An  insurer  shall  complete  review  of  the health care professional's
    29  application to participate in the in-network portion  of  the  insurer's
    30  network and, within sixty days of receiving a health care professional's
    31  completed  application  to  participate  in  the insurer's network, will
    32  notify the health care professional as to: (A)  whether  he  or  she  is
    33  credentialed;  or  (B)  whether  additional  time is necessary to make a
    34  determination because of a failure of a third party to provide necessary
    35  documentation. In such instances  where  additional  time  is  necessary
    36  because  of  a  lack  of  necessary documentation, an insurer shall make
    37  every effort to obtain such information as soon as  possible  and  shall
    38  make  a  final  determination  within  twenty-one  days of receiving the
    39  necessary documentation. The plans shall also  implement  procedures  to
    40  permit  newly  licensed  health  care  professionals  to render care and
    41  receive payment for care provided to enrollees on  a  provisional  basis
    42  during  the  pendency  of the application process of such newly licensed
    43  health care professionals.
    44    (2) If the completed  application  of  a  newly-licensed  health  care
    45  professional or a health care professional who has recently relocated to
    46  this  state  from another state and has not previously practiced in this
    47  state, who joins a group practice of health care professionals  each  of
    48  whom  participates in the in-network portion of an insurer's network, is
    49  neither approved nor declined within  sixty  days  of  submission  of  a
    50  completed application pursuant to paragraph one of this subsection, such
    51  health  care  professional  shall be deemed "provisionally credentialed"
    52  and may participate in the in-network portion of an  insurer's  network;
    53  provided,  however,  that a provisionally credentialed physician may not
    54  be designated as an insured's primary care physician until such time  as
    55  the physician has been fully credentialed. The network participation for
    56  a provisionally credentialed health care professional shall begin on the

        S. 4335                             4
     1  day  following  the sixtieth day of receipt of the completed application
     2  and shall last until the final credentialing determination  is  made  by
     3  the  insurer.  A  health  care  professional  shall only be eligible for
     4  provisional  credentialing  if the group practice of health care profes-
     5  sionals notifies the insurer in writing  that,  should  the  application
     6  ultimately  be  denied,  the health care professional or the group prac-
     7  tice: (A) shall refund any payments made by the insurer  for  in-network
     8  services  provided by the provisionally credentialed health care profes-
     9  sional  that  exceed  any  out-of-network  benefits  payable  under  the
    10  insured's contract with the insurer; and (B) shall not pursue reimburse-
    11  ment  from  the  insured, except to collect the copayment or coinsurance
    12  that otherwise would have been payable had the insured received services
    13  from a health care professional participating in the in-network  portion
    14  of  an  insurer's  network.  Interest  and penalties pursuant to section
    15  three thousand two hundred twenty-four-a of this chapter  shall  not  be
    16  assessed based on the denial of a claim submitted during the period when
    17  the  health  care professional was provisionally credentialed; provided,
    18  however, that nothing herein shall prevent  an  insurer  from  paying  a
    19  claim  from a health care professional who is provisionally credentialed
    20  upon submission of such claim. An insurer shall not deny, after  appeal,
    21  a  claim  for  services  provided by a provisionally credentialed health
    22  care professional solely on the ground that the  claim  was  not  timely
    23  filed.
    24    (3)  The  superintendent,  in  consultation  with  the commissioner of
    25  health, and representatives of health care plans, hospitals, and  health
    26  care  professionals  shall  adopt  by regulation a universal health care
    27  professional application for participation form,  and  a  form  for  the
    28  renewal  of  credentialing  which shall be an abbreviated version of the
    29  universal application form for use by  health  care  plans  which  offer
    30  managed  care  products  for the purpose of credentialing and re-creden-
    31  tialing health care professionals who seek to participate  in  a  health
    32  care plan's provider network, including credentialing and re-credential-
    33  ing  health care professionals who are employed or have staff privileges
    34  at hospitals or other health care facilities which seek  to  participate
    35  in a provider network.
    36    (4)  The  superintendent,  in  consultation  with  the commissioner of
    37  health, and representatives of health care plans, hospitals  and  health
    38  care  professionals  shall  adopt  by regulation a universal health care
    39  professional referral form for the purpose of simplifying the process of
    40  referral of patients to other health care professionals.
    41    (5) The superintendent,  in  consultation  with  the  commissioner  of
    42  health,  and  representatives of health care plans, hospitals and health
    43  care professionals shall revise the  universal  application,  re-creden-
    44  tialing  and universal health care professional referral forms as neces-
    45  sary, to conform with industry-wide, national standards  of  credential-
    46  ing, re-credentialing and health care referral.
    47    (6)  In  developing the universal health care professional application
    48  re-credentialing forms, the superintendent shall ensure that the creden-
    49  tialing and re-credentialing requirements for participation in the medi-
    50  caid program and the state child  health  plus  program  are  adequately
    51  reflected on the health care professional application and re-credential-
    52  ing forms.
    53    (7) The credentialing and re-credentialing forms required for develop-
    54  ment  under this subsection shall be the only forms that may be used for
    55  credentialing and re-credentialing health care professionals  by  insur-
    56  ers, hospitals and other health care facilities.

        S. 4335                             5
     1    (8) The professional referral form required for development under this
     2  subsection  shall  be the only form that an insurer may require a health
     3  care professional to use for  the  purposes  of  making  a  professional
     4  referral;  provided,  however,  that  an  insurer may request additional
     5  patient  information  separately from the professional referral form for
     6  the purposes of reviewing such professional referral.
     7    § 3. This act shall take effect on the one hundred eightieth day after
     8  it shall have become a law.
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