NY State Senate Bill 2011-S4511

Archive: Last Bill Status - In Senate Committee Health Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 04, 2012	referred to health
Apr 08, 2011	referred to health

co-Sponsors

2011-S4511 (ACTIVE) - Details

See Assembly Version of this Bill:: A575
Current Committee:: Senate Health
Law Section:: Public Health Law
Laws Affected:: Amd §4406-d, Pub Health L; amd §4803, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: S3905, A764
2013-2014: A2673
2015-2016: A443
2017-2018: A2389
2019-2020: A3077

2011-S4511 (ACTIVE) - Summary

Relates to certain application and referral forms for health care plans by authorizing the commissioner and superintendent of insurance to adopt regulations for the renewal of credentialing and re-credentialing of newly licensed health care professionals.

2011-S4511 (ACTIVE) - Sponsor Memo

                                BILL NUMBER:S4511

TITLE OF BILL:
An act
to amend the public health law and the insurance law, in relation to
certain application and referral forms for health care plans

PURPOSE OR GENERAL IDEA OF BILL:
To streamline and simplify the
process by which physicians and other health care professionals are
credentialed by health care plans and hospitals, as well as to
standardize the referral forms that primary care physicians use to
facilitate care for a patient by a specialist physician.

SUMMARY OF SPECIFIC PROVISIONS:
This bill amends section 4406-d,
subdivision (I) of the public Health Law to create new paragraphs (c),
(d), (e), (f), (a) and (h) that would establish a process for creating
a standardized credentialing and renewal form for physicians and
other health care professionals to use for the purpose of being
accepted and retained on the panels of health care plans, as well as
for the purpose of obtaining staff privileges at a hospital or other
health care facility. Such credentialing form would be required to
include provisions that would ensure that the form would be
applicable for physician participation in the networks of government
sponsored health plans, including Medicaid, Child Health Plus and

Family Health Plus. It would also establish a similar process for
creating a uniform referral form that physicians and other health
care professionals may use in referring patients for specialty care.
In addition, it would establish this universal referral form as the
sole source of information required for credentialing,
re-credentialing, and professional referrals.

JUSTIFICATION:
Physicians currently need to spend an extensive amount
of time completing paperwork in order to be credentialed by health
care plans for participation in their networks, and by hospitals to
be granted employment of staff privileges. Credentialing is the
process by which physicians present documentation of their
professional privileges, licensure, evidence of malpractice insurance
and malpractice history to such health care plan or hospital for
their review. While this is an important process for ensuring that a
physician who will provide care for the enrollees of a health plan,
or of the patients at a hospital, is properly qualified, the process
can be unnecessarily cumbersome. Most insurers have different forms
that essentially ask for the same information, creating additional
unnecessary paperwork for the physician. This legislation would
simplify this cumbersome process to facilitate the creation of a
uniform credentialing and renewal form, and thereby reduce the
administrative burden physicians currently have in completing these
forms. This legislation calls for the forms to be devised with
collaboration by all parties who regularly complete and review these
forms, including health plans, hospitals, physicians and other
health care providers.


Moreover, this legislation would also establish a similar process for
creating a standard referral form that a primary care physician may
use to facilitate making a referral when a patient needs to receive
care from a specialist physician. As with credentialing forms, health
care plans typically have their own referral authorization forms that
arc substantially similar, but different such that the physician must
use each plan's form. As with the uniform credentialing forms, a
universal referral form would alleviate some of the administrative
hassles that physicians face in attempting to facilitate necessary
care for their patients.

PRIOR LEGISLATIVE HISTORY:
2002:    A.10483-A - Advanced to third reading
2003-04: A.5013    - Passed the Assembly
2005-06: A.5405    - Passed Assembly
2007-08: A.8163    - Passed Assembly
2009-10: A.764-A   - Passed Assembly

FISCAL IMPLICATIONS:
None.

EFFECTIVE DATE:
This act shall take effect 180 days after it has become law.

2011-S4511 (ACTIVE) - Bill Text download pdf

                            
                    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.

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Senate Bill S4511

Sponsored By

Archive: Last Bill Status - In Senate Committee Health Committee

co-Sponsors

2011-S4511 (ACTIVE) - Details

2011-S4511 (ACTIVE) - Summary

2011-S4511 (ACTIVE) - Sponsor Memo

2011-S4511 (ACTIVE) - Bill Text download pdf

Comments

Senate Bill S4511

Share this bill

Sponsored By

Kemp Hannon

Archive: Last Bill Status - In Senate Committee Health Committee

co-Sponsors

John A. DeFrancisco

Liz Krueger

Michael H. Ranzenhofer

2011-S4511 (ACTIVE) - Details

2011-S4511 (ACTIVE) - Summary

2011-S4511 (ACTIVE) - Sponsor Memo

2011-S4511 (ACTIVE) - Bill Text download pdf

Comments