Bill Text: NY S05328 | 2019-2020 | General Assembly | Amended

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Bill Title: Relates to denial of coverage of additional or related services or procedures related to health care services for which pre-authorization was granted or did not require pre-authorization.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Passed) 2019-12-12 - SIGNED CHAP.640 [S05328 Detail]

Download: New_York-2019-S05328-Amended.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                         5328--A

                               2019-2020 Regular Sessions

                    IN SENATE

                                     April 26, 2019
                                       ___________

        Introduced  by  Sen. BRESLIN -- read twice and ordered printed, and when
          printed to be committed to the Committee  on  Insurance  --  committee
          discharged, bill amended, ordered reprinted as amended and recommitted
          to said committee

        AN  ACT to amend the insurance law, in relation to denial of coverage of
          additional or related services or procedures related  to  health  care
          services  for  which  pre-authorization was granted or did not require
          pre-authorization; and to repeal certain provisions of such law relat-
          ing thereto

          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:

     1    Section  1.    Subsection  (c) of section 3238 of the insurance law is
     2  REPEALED and a new subsection (c) is added to read as follows:
     3    (c)(1) If a health care provider, while providing a service or  proce-
     4  dure  to  treat  a  patient,  determines that providing an additional or
     5  related service or procedure, such as a service or procedure to  address
     6  a  co-morbid  condition, is immediately necessary as part of such treat-
     7  ment, and in the clinical judgment of the health care provider it  is  a
     8  medically  timely  service  and  it  would not be medically advisable to
     9  interrupt the provision of care to the patient in order to  obtain  pre-
    10  authorization  from  a health plan for the additional or related service
    11  or procedure, a denial of payment for the additional or related  service
    12  or  procedure due to lack of pre-authorization shall be upheld on appeal
    13  only if it is determined that:
    14    (i) the additional or related service or procedure is  not  a  covered
    15  benefit;
    16    (ii)  the additional or related service or procedure was not medically
    17  necessary pursuant to section four thousand nine hundred  four  of  this
    18  chapter or section forty-nine hundred four of the public health law;
    19    (iii)  the additional or related service or procedure was experimental
    20  or investigational pursuant to section four thousand nine  hundred  four

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD04761-06-9
        S. 5328--A                          2

     1  of  this chapter or section forty-nine hundred four of the public health
     2  law; or
     3    (iv)  one of the conditions set forth in paragraphs one through six of
     4  subsection (a) of this section is met.
     5    (2) The provisions of this subsection shall  apply  to  situations  in
     6  which  pre-authorization  was  required  and  received  for  the initial
     7  service or procedure.
     8    (3) The provisions of this subsection shall apply  without  regard  to
     9  whether the current procedural terminology (CPT) code for the additional
    10  or  related  service or procedure is different than the CPT code for the
    11  initial service or procedure.
    12    § 2. This act shall take effect on the ninetieth day  after  it  shall
    13  have become a law.