S T A T E   O F   N E W   Y O R K
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                                  8398

                       2011-2012 Regular Sessions

                          I N  A S S E M B L Y

                              June 15, 2011
                               ___________

Introduced  by M. of A. RUSSELL -- read once and referred to the Commit-
  tee on Insurance

AN ACT to amend the insurance law, in relation to provider credentialing

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Subsection  (a)  of  section 4803 of the insurance law is
amended by adding a new paragraph 3 to read as follows:
  (3) A NEWLY-LICENSED HEALTH CARE PROFESSIONAL, A HEALTH  CARE  PROFES-
SIONAL  WHO  HAS RECENTLY RELOCATED TO THIS STATE FROM ANOTHER STATE AND
HAS NOT PREVIOUSLY PRACTICED IN THIS  STATE,  OR  A  PHYSICIAN  WHO  HAS
CHANGED  THEIR  CORPORATE RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSU-
ANCE OF A NEW TAX IDENTIFICATION NUMBER UNDER WHICH THEIR  SERVICES  ARE
BILLED  FOR,  WHO IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO
ARTICLE TWENTY-EIGHT OF THE PUBLIC  HEALTH  LAW,  WHOSE  OTHER  EMPLOYED
HEALTH  CARE  PROFESSIONALS  PARTICIPATE IN THE IN-NETWORK PORTION OF AN
INSURER'S NETWORK, SHALL BE DEEMED "PROVISIONALLY CREDENTIALED" UPON THE
PLAN'S RECEIPT OF THE COMPLETED APPLICATION, 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 CREDENTIALED BY THE PLAN.  A HEALTH CARE  PROFESSIONAL  SHALL
ONLY  BE  ELIGIBLE FOR PROVISIONAL CREDENTIALING IF THE GENERAL HOSPITAL
LICENSED PURSUANT TO ARTICLE TWENTY-EIGHT OF THE PUBLIC HEALTH LAW  WITH
WHICH  HE  OR  SHE  IS EMPLOYED NOTIFIES THE INSURER IN WRITING THAT THE
HEALTH CARE PROFESSIONAL HAS BEEN GRANTED  HOSPITAL  PRIVILEGES    AFTER
MEETING  THE  REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED FIVE-K OF THE
PUBLIC HEALTH LAW AND, SHOULD THE APPLICATION ULTIMATELY BE DENIED,  THE
LICENSED  GENERAL  HOSPITAL:  (A)  SHALL REFUND ANY PAYMENTS MADE BY THE
INSURER FOR IN-NETWORK SERVICES PROVIDED BY  THE  PROVISIONALLY  CREDEN-
TIALED  HEALTH CARE PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS
PAYABLE UNDER THE INSURED'S CONTRACT WITH THE INSURER; AND (B) SHALL NOT

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD11200-01-1
              

A. 8398                             2

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 PROFESSIONAL PARTICIPATING  IN  THE
IN-NETWORK PORTION OF AN INSURER'S NETWORK.
  S  2.  This  act shall take effect on the ninetieth day after it shall
have become a law, and shall apply to applications submitted after  such
date and shall not apply to applications submitted prior to such date if
such  application  is  resubmitted  in  substantially similar form on or
after the effective date of this act.