S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 3905--A

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                              April 3, 2009
                               ___________

Introduced  by  Sen.  DUANE  -- read twice and ordered printed, and when
  printed to be committed to the Committee on Health --  recommitted  to
  the  Committee  on  Health in accordance with Senate Rule 6, sec. 8 --
  committee discharged, bill amended, ordered reprinted as  amended  and
  recommitted to said committee

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:

  Section 1. Subdivision 1 of section 4406-d of the public  health  law,
as  amended  by  chapter  237 of the laws of 2009, is amended to read as
follows:
  1. (a) A health care plan shall,  upon  request,  make  available  and
disclose to health care professionals written application procedures and
minimum qualification requirements which a health care professional must
meet  in  order to be considered by the health care plan. The plan shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements. A health care plan shall  complete
review  of  the health care professional's UNIVERSAL HEALTH CARE PROFES-
SIONAL application [to participate] FOR PARTICIPATION in the  in-network
portion  of the health care plan's network and shall, within ninety days
of receiving a health care professional's completed  UNIVERSAL  applica-
tion to participate in the health care plan's network, notify the health
care  professional as to: (i) whether he or she is credentialed; or (ii)
whether additional time is necessary to make a determination in spite of
the health care plan's best efforts or because of a failure of  a  third
party  to  provide  necessary  documentation,  or non-routine or unusual
circumstances require additional time  for  review.  In  such  instances
where  additional  time  is  necessary  because  of  a lack of necessary
documentation, a health plan shall make  every  effort  to  obtain  such
information as soon as possible.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01107-03-0
              

S. 3905--A                          2

  (b)  If  the  completed  application  of  a newly-licensed health care
professional or a health care professional who has recently relocated to
this state from another state and has not previously practiced  in  this
state,  who  joins a group practice of health care professionals each of
whom  participates  in  the  in-network  portion of a health care plan's
network, is neither approved nor declined within ninety days pursuant to
paragraph (a) of this subdivision, the health care professional shall be
deemed "provisionally credentialed" and may participate in  the  in-net-
work  portion of the health care plan's network; provided, however, that
a provisionally credentialed physician  may  not  be  designated  as  an
enrollee's  primary  care physician until such time as the physician has
been fully credentialed. The network participation for  a  provisionally
credentialed  health  care professional shall begin on the day following
the ninetieth day of receipt of the completed application and shall last
until the final credentialing determination is made by the  health  care
plan.  A health care professional shall only be eligible for provisional
credentialing if the group practice of health care  professionals  noti-
fies  the health care plan in writing that, should the application ulti-
mately be denied, the health care professional or  the  group  practice:
(i)  shall  refund any payments made by the health care plan for in-net-
work services provided by the  provisionally  credentialed  health  care
professional  that  exceed any out-of-network benefits payable under the
enrollee's contract with the health care plan; and (ii) shall not pursue
reimbursement from the enrollee, except to collect  the  copayment  that
otherwise  would  have  been  payable had the enrollee received services
from a health care professional participating in the in-network  portion
of  a  health  care  plan's  network. Interest and penalties pursuant to
section three thousand two hundred twenty-four-a of  the  insurance  law
shall  not  be  assessed based on the denial of a claim submitted during
the period when the health care professional was  provisionally  creden-
tialed;  provided,  however,  that nothing herein shall prevent a health
care plan from paying a claim from a health  care  professional  who  is
provisionally  credentialed upon submission of such claim. A health care
plan shall not deny, after appeal, a claim for services  provided  by  a
provisionally credentialed health care professional solely on the ground
that the claim was not timely filed.
  (C)  THE  COMMISSIONER,  IN  CONSULTATION  WITH  THE SUPERINTENDENT OF
INSURANCE, AND REPRESENTATIVES  OF  HEALTH  CARE  PLANS,  HOSPITALS  AND
HEALTH  CARE  PROFESSIONALS  SHALL  ADOPT  BY  REGULATION SUCH UNIVERSAL
HEALTH CARE PROFESSIONAL APPLICATION FOR PARTICIPATION FORM, AND A  FORM
FOR  THE  RENEWAL OF CREDENTIALING WHICH SHALL BE AN ABBREVIATED VERSION
OF THE UNIVERSAL APPLICATION FORM, FOR USE BY HEALTH  CARE  PLANS  WHICH
OFFER MANAGED CARE PRODUCTS FOR THE PURPOSE OF CREDENTIALING AND RE-CRE-
DENTIALING HEALTH CARE PROFESSIONALS WHO SEEK TO PARTICIPATE IN A HEALTH
CARE  PLAN'S  PROVIDER  NETWORK AND FOR THE PURPOSE OF CREDENTIALING AND
RE-CREDENTIALING HEALTH CARE PROFESSIONALS  WHO  ARE  EMPLOYED  OR  HAVE
STAFF PRIVILEGES AT HOSPITALS OR OTHER HEALTH CARE FACILITIES WHICH SEEK
TO PARTICIPATE IN A PROVIDER NETWORK.
  (D)  THE  COMMISSIONER,  IN  CONSULTATION  WITH  THE SUPERINTENDENT OF
INSURANCE, AND REPRESENTATIVES  OF  HEALTH  CARE  PLANS,  HOSPITALS  AND
HEALTH  CARE  PROFESSIONALS SHALL ADOPT BY REGULATION A UNIVERSAL HEALTH
CARE PROFESSIONAL REFERRAL FORM FOR THE PURPOSE OF SIMPLIFYING THE PROC-
ESS OF REFERRAL OF PATIENTS TO OTHER HEALTH CARE PROFESSIONALS.
  (E) THE COMMISSIONER,  IN  CONSULTATION  WITH  THE  SUPERINTENDENT  OF
INSURANCE,  AND  REPRESENTATIVES  OF  HEALTH  CARE  PLANS, HOSPITALS AND
HEALTH  CARE  PROFESSIONALS  SHALL  REVISE  THE  UNIVERSAL  APPLICATION,

S. 3905--A                          3

RE-CREDENTIALING  AND  UNIVERSAL HEALTH CARE PROFESSIONAL REFERRAL FORMS
AS NECESSARY, TO  CONFORM  WITH  INDUSTRY-WIDE,  NATIONAL  STANDARDS  OF
CREDENTIALING, RE-CREDENTIALING AND HEALTH CARE REFERRAL.
  (F)  IN  DEVELOPING THE UNIVERSAL HEALTH CARE PROFESSIONAL APPLICATION
RE-CREDENTIALING FORMS, THE COMMISSIONER SHALL ENSURE THAT  THE  CREDEN-
TIALING AND RE-CREDENTIALING REQUIREMENTS FOR PARTICIPATION IN THE MEDI-
CAID  PROGRAM, THE STATE CHILD HEALTH PLUS PROGRAM AND THE FAMILY HEALTH
PLUS PROGRAMS ARE ADEQUATELY REFLECTED ON THE HEALTH  CARE  PROFESSIONAL
APPLICATION AND RE-CREDENTIALING FORMS.
  (G)  ALL  THE  CREDENTIALING  AND  RE-CREDENTIALING FORMS REQUIRED FOR
DEVELOPMENT UNDER THIS SUBDIVISION SHALL BE THE ONLY FORMS THAT  MAY  BE
USED FOR CREDENTIALING AND RE-CREDENTIALING HEALTH CARE PROFESSIONALS BY
HEALTH CARE PLANS, HOSPITALS, AND OTHER HEALTH CARE FACILITIES.
  (H) THE PROFESSIONAL REFERRAL FORM REQUIRED FOR DEVELOPMENT UNDER THIS
SUBDIVISION SHALL BE THE ONLY FORM THAT A HEALTH CARE PLAN MAY REQUIRE A
HEALTH  CARE  PROFESSIONAL  TO  USE FOR THE PURPOSES OF MAKING A PROFES-
SIONAL REFERRAL; PROVIDED, HOWEVER, THAT A HEALTH CARE PLAN MAY  REQUEST
ADDITIONAL PATIENT INFORMATION SEPARATELY FROM THE PROFESSIONAL REFERRAL
FORM FOR THE PURPOSES OF REVIEWING SUCH PROFESSIONAL REFERRAL.
  S  2.  Subsection (a) of section 4803 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (a) (1) An insurer which offers a managed  care  product  shall,  upon
request,  make available and disclose to health care professionals writ-
ten application procedures and minimum qualification requirements  which
a  health  care  professional must meet in order to be considered by the
insurer for participation in the  in-network  benefits  portion  of  the
insurer's  network  for  the  managed  care  product.  The insurer shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits portion of the insurer's network for the managed care  product.
An  insurer  shall  complete  review  of  the health care professional's
application to participate in the in-network portion  of  the  insurer's
network  and,  within  ninety  days  of  receiving a health care profes-
sional's completed application to participate in the insurer's  network,
will notify the health care professional as to: (A) whether he or she is
credentialed;  or  (B)  whether  additional  time is necessary to make a
determination in spite of the insurer's best efforts  or  because  of  a
failure  of  a  third  party to provide necessary documentation, or non-
routine or unusual circumstances require additional time for review.  In
such instances where additional time is necessary because of a  lack  of
necessary  documentation,  an  insurer shall make every effort to obtain
such information as soon as possible.   THE PLANS SHALL  ALSO  IMPLEMENT
PROCEDURES  TO PERMIT NEWLY LICENSED HEALTH CARE PROFESSIONALS TO RENDER
CARE AND RECEIVE PAYMENT FOR CARE PROVIDED TO ENROLLEES ON A PROVISIONAL
BASIS DURING THE PENDENCY OF  THE  APPLICATION  PROCESS  OF  SUCH  NEWLY
LICENSED HEALTH CARE PROFESSIONALS.
  (2)  If  the  completed  application  of  a newly-licensed health care
professional or a health care professional who has recently relocated to
this state from another state and has not previously practiced  in  this
state,  who  joins a group practice of health care professionals each of
whom participates in the in-network portion of an insurer's network,  is
neither  approved  nor declined within ninety days pursuant to paragraph
one of this subsection, such health care professional  shall  be  deemed
"provisionally  credentialed"  and  may  participate  in  the in-network
portion of an insurer's network; provided, however, that a provisionally
credentialed physician may not be designated  as  an  insured's  primary

S. 3905--A                          4

care  physician  until such time as the physician has been fully creden-
tialed. The  network  participation  for  a  provisionally  credentialed
health  care professional shall begin on the day following the ninetieth
day  of  receipt  of  the completed application and shall last until the
final credentialing determination is made by the insurer. A health  care
professional shall only be eligible for provisional credentialing if the
group  practice  of  health  care  professionals notifies the insurer in
writing that, should the application ultimately be  denied,  the  health
care  professional  or the group practice: (A) shall refund any payments
made by the insurer for  in-network  services  provided  by  the  provi-
sionally  credentialed  health care professional that exceed any out-of-
network benefits payable under the insured's contract with the  insurer;
and  (B)  shall  not  pursue  reimbursement  from the insured, except to
collect the copayment or coinsurance  that  otherwise  would  have  been
payable  had  the  insured  received services from a health care profes-
sional participating in the in-network portion of an insurer's  network.
Interest  and  penalties  pursuant to section three thousand two hundred
twenty-four-a of this chapter shall not be assessed based on the  denial
of a claim submitted during the period when the health care professional
was  provisionally  credentialed; provided, however, that nothing herein
shall prevent an insurer from paying a claim from a health care  profes-
sional  who is provisionally credentialed upon submission of such claim.
An insurer shall not deny, after appeal, a claim for  services  provided
by  a  provisionally credentialed health care professional solely on the
ground that the claim was not timely filed.
  (3) THE SUPERINTENDENT,  IN  CONSULTATION  WITH  THE  COMMISSIONER  OF
HEALTH,  AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS, AND HEALTH
CARE PROFESSIONALS SHALL ADOPT BY REGULATION  A  UNIVERSAL  HEALTH  CARE
PROFESSIONAL  APPLICATION  FOR  PARTICIPATION  FORM,  AND A FORM FOR THE
RENEWAL OF CREDENTIALING WHICH SHALL BE AN ABBREVIATED  VERSION  OF  THE
UNIVERSAL  APPLICATION  FORM  FOR  USE  BY HEALTH CARE PLANS WHICH OFFER
MANAGED CARE PRODUCTS FOR THE PURPOSE OF  CREDENTIALING  AND  RE-CREDEN-
TIALING  HEALTH  CARE  PROFESSIONALS WHO SEEK TO PARTICIPATE IN A HEALTH
CARE PLAN'S PROVIDER NETWORK AND FOR THE PURPOSE  OF  CREDENTIALING  AND
RE-CREDENTIALING  HEALTH  CARE  PROFESSIONALS  WHO  ARE EMPLOYED OR HAVE
STAFF PRIVILEGES AT HOSPITALS OR OTHER HEALTH CARE FACILITIES WHICH SEEK
TO PARTICIPATE IN A PROVIDER NETWORK.
  (4) THE SUPERINTENDENT,  IN  CONSULTATION  WITH  THE  COMMISSIONER  OF
HEALTH,  AND  REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS AND HEALTH
CARE PROFESSIONALS SHALL ADOPT BY REGULATION  A  UNIVERSAL  HEALTH  CARE
PROFESSIONAL REFERRAL FORM FOR THE PURPOSE OF SIMPLIFYING THE PROCESS OF
REFERRAL OF PATIENTS TO OTHER HEALTH CARE PROFESSIONALS.
  (5)  THE  SUPERINTENDENT,  IN  CONSULTATION  WITH  THE COMMISSIONER OF
HEALTH, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS  AND  HEALTH
CARE  PROFESSIONALS  SHALL  REVISE THE UNIVERSAL APPLICATION, RE-CREDEN-
TIALING AND UNIVERSAL HEALTH CARE PROFESSIONAL REFERRAL FORMS AS  NECES-
SARY,  TO  CONFORM WITH INDUSTRY-WIDE, NATIONAL STANDARDS OF CREDENTIAL-
ING, RE-CREDENTIALING AND HEALTH CARE REFERRAL.
  (6) IN DEVELOPING THE UNIVERSAL HEALTH CARE  PROFESSIONAL  APPLICATION
RE-CREDENTIALING FORMS, THE SUPERINTENDENT SHALL ENSURE THAT THE CREDEN-
TIALING AND RE-CREDENTIALING REQUIREMENTS FOR PARTICIPATION IN THE MEDI-
CAID  PROGRAM, THE STATE CHILD HEALTH PLUS PROGRAM AND THE FAMILY HEALTH
PLUS PROGRAMS ARE ADEQUATELY REFLECTED ON THE HEALTH  CARE  PROFESSIONAL
APPLICATION AND RE-CREDENTIALING FORMS.
  (7) THE CREDENTIALING AND RE-CREDENTIALING FORMS REQUIRED FOR DEVELOP-
MENT  UNDER THIS SUBSECTION SHALL BE THE ONLY FORMS THAT MAY BE USED FOR

S. 3905--A                          5

CREDENTIALING AND RE-CREDENTIALING HEALTH CARE PROFESSIONALS  BY  INSUR-
ERS, HOSPITALS AND OTHER HEALTH CARE FACILITIES.
  (8) THE PROFESSIONAL REFERRAL FORM REQUIRED FOR DEVELOPMENT UNDER THIS
SUBSECTION  SHALL  BE THE ONLY FORM THAT AN INSURER MAY REQUIRE A HEALTH
CARE PROFESSIONAL TO USE FOR  THE  PURPOSES  OF  MAKING  A  PROFESSIONAL
REFERRAL;  PROVIDED,  HOWEVER,  THAT  AN  INSURER MAY REQUEST ADDITIONAL
PATIENT INFORMATION SEPARATELY FROM THE PROFESSIONAL REFERRAL  FORM  FOR
THE PURPOSES OF REVIEWING SUCH PROFESSIONAL REFERRAL.
  S 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.