S T A T E O F N E W Y O R K
________________________________________________________________________
4511
2011-2012 Regular Sessions
I N S E N A T E
April 8, 2011
___________
Introduced by Sen. HANNON -- read twice and ordered printed, and when
printed to be committed 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
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
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02271-01-1
S. 4511 2
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,
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.
S. 4511 3
(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
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
S. 4511 4
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
CREDENTIALING AND RE-CREDENTIALING HEALTH CARE PROFESSIONALS BY INSUR-
ERS, HOSPITALS AND OTHER HEALTH CARE FACILITIES.
S. 4511 5
(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.
