Bill Text: NY S04453 | 2011-2012 | 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 3-0)
Status: (Introduced - Dead) 2012-03-15 - PRINT NUMBER 4453A [S04453 Detail]
Download: New_York-2011-S04453-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
4453
2011-2012 Regular Sessions
I N S E N A T E
April 6, 2011
___________
Introduced by Sens. DeFRANCISCO, LARKIN -- read twice and ordered print-
ed, 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;
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD08992-01-1
S. 4453 2
1 (ii) where applicable, is board certified or board eligible in the
2 same [or similar] specialty as the health care provider who typically
3 manages the medical condition or disease or provides the health care
4 service or treatment under appeal;
5 (iii) has been practicing in such area of specialty for a period of at
6 least five years; and
7 (iv) is knowledgeable about the health care service or treatment under
8 appeal; 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 ISSUED PURSUANT TO TITLE EIGHT OF
12 THE EDUCATION LAW;
13 (ii) where applicable, is credentialed by the national accrediting
14 body appropriate to the profession in the same profession and same [or
15 similar] specialty as the health care provider who typically manages the
16 medical condition or disease or provides the health care service or
17 treatment under appeal;
18 (iii) has been practicing in such area of specialty for a period of at
19 least five years;
20 (iv) is knowledgeable about the health care service or treatment under
21 appeal; and
22 (v) where applicable to such health care professional's scope of prac-
23 tice, is clinically supported by a physician who possesses a current and
24 valid non-restricted license to practice medicine PURSUANT TO ARTICLE
25 ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW.
26 (3) Nothing [herein] IN THIS ARTICLE shall be construed to change any
27 statutorily-defined scope of practice.
28 S 2. Subdivision 2 of section 4900 of the public health law, as
29 amended by chapter 586 of the laws of 1998, is amended to read as
30 follows:
31 2. "Clinical peer reviewer" means:
32 (a) for purposes of title one of this article:
33 (i) a physician who possesses a current and valid non-restricted
34 license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE
35 OF THE EDUCATION LAW; or
36 (ii) a health care professional other than a licensed physician who:
37 (A) where applicable, possesses a current and valid non-restricted
38 license, certificate or registration [or, where no provision for a
39 license, certificate or registration exists, is credentialed by the
40 national accrediting body appropriate to the profession] ISSUED PURSUANT
41 TO TITLE EIGHT OF THE EDUCATION LAW; and
42 (B) is in the same profession and same [or similar] specialty as the
43 health care provider who typically manages the medical condition or
44 disease or provides the health care service or treatment under review;
45 and
46 (b) for purposes of title two of this article:
47 (i) a physician who:
48 (A) possesses a current and valid non-restricted license to practice
49 medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION
50 LAW;
51 (B) where applicable, is board certified or board eligible in the same
52 [or similar] specialty as the health care provider who typically manages
53 the medical condition or disease or provides the health care service or
54 treatment under appeal;
55 (C) has been practicing in such area of specialty for a period of at
56 least five years; and
S. 4453 3
1 (D) is knowledgeable about the health care service or treatment under
2 appeal; or
3 (ii) a health care professional other than a licensed physician who:
4 (A) where applicable, possesses a current and valid non-restricted
5 license, certificate or registration ISSUED PURSUANT TO TITLE EIGHT OF
6 THE EDUCATION LAW;
7 (B) where applicable, is credentialed by the national accrediting body
8 appropriate to the profession in the same profession and same [or simi-
9 lar] specialty as the health care provider who typically manages the
10 medical condition or disease or provides the health care service or
11 treatment under appeal;
12 (C) has been practicing in such area of specialty for a period of at
13 least five years;
14 (D) is knowledgeable about the health care service or treatment under
15 appeal; and
16 (E) where applicable to such health care professional's scope of prac-
17 tice, is clinically supported by a physician who possesses a current and
18 valid non-restricted license to practice medicine PURSUANT TO ARTICLE
19 ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW.
20 (c) Nothing [herein] IN THIS ARTICLE shall be construed to change any
21 statutorily-defined scope of practice.
22 S 3. This act shall take effect on the one hundred twentieth day after
23 it shall have become a law.
