Bill Text: NY S08844 | 2019-2020 | General Assembly | Introduced
Bill Title: Relates to the definition of a clinical peer reviewer by clarifying that such term shall be applicable for the entire utilization review and external appeal article and means either a physician or a health care professional with certain qualifications.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2020-07-29 - REFERRED TO RULES [S08844 Detail]
Download: New_York-2019-S08844-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 8844 IN SENATE July 29, 2020 ___________ Introduced by Sen. BENJAMIN -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the public health law and the insurance law, in relation to the definition of clinical peer reviewer The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subdivision 2 of section 4900 of the public health law, as 2 amended by chapter 586 of the laws of 1998, item (B) of subparagraph 3 (ii) of paragraph (a) as amended by chapter 41 of the laws of 2014 and 4 subparagraph (iii) as amended and subparagraph (iv) of paragraph (a) as 5 added by section 42 of subpart A of part BB of chapter 57 of the laws of 6 2019, is amended to read as follows: 7 2. "Clinical peer reviewer" means: 8 (a) [for purposes of title one of this article:9(i) a physician who possesses a current and valid non-restricted10license to practice medicine; or11(ii) a health care professional other than a licensed physician who:12(A) where applicable, possesses a current and valid non-restricted13license, certificate or registration or, where no provision for a14license, certificate or registration exists, is credentialed by the15national accrediting body appropriate to the profession; and16(B) is in the same profession and same or similar specialty as the17health care provider who typically manages the medical condition or18disease or provides the health care service or treatment under review;19or20(iii) for purposes of a determination involving substance use disorder21treatment:22(A) a physician who possesses a current and valid non-restricted23license to practice medicine and who specializes in behavioral health24and has experience in the delivery of substance use disorder courses of25treatment; or26(B) a health care professional other than a licensed physician who27specializes in behavioral health and has experience in the delivery of28substance use disorder courses of treatment and, where applicable,EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD03373-04-0S. 8844 2 1possesses a current and valid non-restricted license, certificate or2registration or, where no provision for a license, certificate or regis-3tration exists, is credentialed by the national accrediting body appro-4priate to the profession; or5(iv) for purposes of a determination involving treatment for a mental6health condition:7(A) a physician who possesses a current and valid non-restricted8license to practice medicine and who specializes in behavioral health9and has experience in the delivery of mental health courses of treat-10ment; or11(B) a health care professional other than a licensed physician who12specializes in behavioral health and has experience in the delivery of a13mental health courses of treatment and, where applicable, possesses a14current and valid non-restricted license, certificate, or registration15or, where no provision for a license, certificate or registration16exists, is credentialed by the national accrediting body appropriate to17the profession; and18(b) for purposes of title two of this article:19(i)] a physician who: 20 [(A)] (i) possesses a current and valid non-restricted license to 21 practice medicine under article one hundred thirty-one of the education 22 law; 23 [(B)] (ii) where applicable, is board certified or board eligible in 24 the same or similar specialty as the health care provider who typically 25 manages the medical condition or disease or provides the health care 26 service or treatment under review or appeal; 27 [(C)] (iii) has been practicing in such area of specialty for a period 28 of at least five years; [and] 29 (iv) for purposes of a determination involving substance use disorder 30 treatment, possesses a current and valid non-restricted license to prac- 31 tice medicine and specializes in behavioral health and has experience in 32 the delivery of substance use disorder courses of treatment; 33 (v) for purposes of a determination involving treatment for a mental 34 health condition, possesses a current and valid non-restricted license 35 to practice medicine and who specializes in behavioral health and has 36 experience in the delivery of mental health courses of treatment; and 37 [(D)] (vi) is knowledgeable about the health care service or treatment 38 under review or appeal; or 39 [(ii)] (b) a health care professional other than a licensed physician 40 who possesses a current and valid non-restricted license or certif- 41 ication under title eight of the education law: 42 [(A)] (i) where applicable, possesses a current and valid non-res- 43 tricted license, certificate or registration; 44 [(B)] (ii) where applicable, is credentialed by the national accredit- 45 ing body appropriate to the profession in the same profession and same 46 or similar specialty as the health care provider who typically manages 47 the medical condition or disease or provides the health care service or 48 treatment under review or appeal; 49 [(C)] (iii) has been practicing in such area of specialty for a period 50 of at least five years; 51 [(D)] (iv) is knowledgeable about the health care service or treatment 52 under review or appeal; [and] 53 (v) for purposes of a determination involving substance use disorder, 54 specializes in behavioral health and has experience in the delivery of 55 substance use disorder courses of treatment and, where applicable, 56 possesses a current and valid non-restricted license, certificate orS. 8844 3 1 registration or, where no provision for a license, certificate or regis- 2 tration exists, is credentialed by the national accrediting body appro- 3 priate to the profession; 4 (vi) for purposes of a determination involving treatment for a mental 5 health condition, specializes in behavioral health and has experience in 6 the delivery of mental health courses of treatment and, where applica- 7 ble, possesses a current and valid non-restricted license, certificate, 8 or registration or, where no provision for a license, certificate or 9 registration exists, is credentialed by the national accrediting body 10 appropriate to the profession; and 11 [(E)] (vii) where applicable to such health care professional's scope 12 of practice, is clinically supported by a physician who possesses a 13 current and valid non-restricted license to practice medicine. 14 [(c)] Nothing [herein] in this subdivision shall be construed to 15 change any statutorily-defined scope of practice. 16 § 2. Subsection (b) of section 4900 of the insurance law, as amended 17 by chapter 586 of the laws of 1998, item (ii) of subparagraph (B) of 18 paragraph 1 as amended by chapter 41 of the laws of 2014, subparagraph 19 (C) as amended and subparagraph (D) of paragraph 1 as added by section 20 36 of subpart A of part BB of chapter 57 of the laws of 2019, is amended 21 to read as follows: 22 (b) "Clinical peer reviewer" means: 23 (1) [for purposes of title one of this article:24(A) a physician who possesses a current and valid non-restricted25license to practice medicine; or26(B) a health care professional other than a licensed physician who:27(i) where applicable, possesses a current and valid non-restricted28license, certificate or registration or, where no provision for a29license, certificate or registration exists, is credentialed by the30national accrediting body appropriate to the profession; and31(ii) is in the same profession and same or similar specialty as the32health care provider who typically manages the medical condition or33disease or provides the health care service or treatment under review;34or35(C) for purposes of a determination involving substance use disorder36treatment:37(i) a physician who possesses a current and valid non-restricted38license to practice medicine and who specializes in behavioral health39and has experience in the delivery of substance use disorder courses of40treatment; or41(ii) a health care professional other than a licensed physician who42specializes in behavioral health and has experience in the delivery of43substance use disorder courses of treatment and, where applicable,44possesses a current and valid non-restricted license, certificate or45registration or, where no provision for a license, certificate or regis-46tration exists, is credentialed by the national accrediting body appro-47priate to the profession; or48(D) for purposes of a determination involving treatment for a mental49health condition:50(i) a physician who possesses a current and valid non-restricted51license to practice medicine and who specializes in behavioral health52and has experience in the delivery of mental health courses of treat-53ment; or54(ii) a health care professional other than a licensed physician who55specializes in behavioral health and has experience in the delivery of56mental health courses of treatment and, where applicable, possesses aS. 8844 4 1current and valid non-restricted license, certificate, or registration2or, where no provision for a license, certificate or registration3exists, is credentialed by the national accrediting body appropriate to4the profession; and5(2) for purposes of title two of this article:6(A)] a physician who: 7 [(i)] (A) possesses a current and valid non-restricted license to 8 practice medicine under article one hundred thirty-one of the education 9 law; 10 [(ii)] (B) where applicable, is board certified or board eligible in 11 the same or similar specialty as the health care provider who typically 12 manages the medical condition or disease or provides the health care 13 service or treatment under review or appeal; 14 [(iii)] (C) has been practicing in such area of specialty for a period 15 of at least five years; [and] 16 (D) for purposes of a determination involving substance use disorder 17 treatment, possesses a current and valid non-restricted license to prac- 18 tice medicine and who specializes in behavioral health and has experi- 19 ence in the delivery of substance use disorder courses of treatment; 20 (E) for purposes of a determination involving treatment for a mental 21 health condition, possesses a current and valid non-restricted license 22 to practice medicine and who specializes in behavioral health and has 23 experience in the delivery of mental health courses of treatment; and 24 [(iv)] (F) is knowledgeable about the health care service or treatment 25 under review or appeal; or 26 [(B)] (2) a health care professional other than a licensed physician 27 who possesses a current and valid non-restricted license or certif- 28 ication under title eight of the education law: 29 [(i)] (A) where applicable, possesses a current and valid non-res- 30 tricted license, certificate or registration; 31 [(ii)] (B) where applicable, is credentialed by the national accredit- 32 ing body appropriate to the profession in the same profession and same 33 or similar specialty as the health care provider who typically manages 34 the medical condition or disease or provides the health care service or 35 treatment under review or appeal; 36 [(iii)] (C) has been practicing in such area of specialty for a period 37 of at least five years; 38 [(iv)] (D) for purposes of a determination involving substance use 39 disorder treatment, specializes in behavioral health and has experience 40 in the delivery of substance use disorder courses of treatment and, 41 where applicable, possesses a current and valid non-restricted license, 42 certificate or registration or, where no provision for a license, 43 certificate or registration exists, is credentialed by the national 44 accrediting body appropriate to the profession; 45 (E) for purposes of a determination involving treatment for a mental 46 health condition, specializes in behavioral health and has experience in 47 the delivery of mental health courses of treatment and, where applica- 48 ble, possesses a current and valid non-restricted license, certificate, 49 or registration or, where no provision for a license, certificate or 50 registration exists, is credentialed by the national accrediting body 51 appropriate to the profession; 52 (F) is knowledgeable about the health care service or treatment under 53 review or appeal; and 54 [(v)] (G) where applicable to such health care professional's scope of 55 practice, is clinically supported by a physician who possesses a current 56 and valid non-restricted license to practice medicine.S. 8844 5 1 [(3)] Nothing [herein] in this subdivision shall be construed to 2 change any statutorily-defined scope of practice. 3 § 3. This act shall take effect on the same date and in the same 4 manner as subpart A of part BB of chapter 57 of the laws of 2019, or on 5 the ninetieth day after it shall have become a law, whichever is later.