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

                                   575

                       2011-2012 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 5, 2011
                               ___________

Introduced  by  M.  of  A.  GOTTFRIED,  CAHILL, CANESTRARI, ENGLEBRIGHT,
  GALEF, ROBINSON, HOYT, LANCMAN --  Multi-Sponsored  by  --  M.  of  A.
  ABBATE,  AUBRY,  BRENNAN,  CLARK,  COLTON, COOK, CYMBROWITZ, DINOWITZ,
  HEASTIE, JACOBS,  KELLNER,  MAYERSOHN,  McENENY,  J. MILLER,  MILLMAN,
  ORTIZ,  PAULIN,  PERRY,  PHEFFER,  PRETLOW,  RAMOS,  J. RIVERA, TITUS,
  TOWNS, WEISENBERG -- read once and referred 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:

  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

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

                                                           LBD02271-01-1

A. 575                              2

documentation,  a  health  plan  shall  make every effort to obtain such
information as soon as possible.
  (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.

A. 575                              3

  (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,
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

A. 575                              4

"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
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

A. 575                              5

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
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.