BILL NUMBER:  S7558

 TITLE OF BILL :  An act to amend the insurance law, in relation to
denial of coverage of treatment related to health care services for
which pre-authorization was granted

 PURPOSE :

To expand the current prior authorization exception for surgical and
invasive procedures to include concurrent symptoms and side effects.

 SUMMARY OF PROVISIONS :

Section 1 of the bill adds a new subsection (c-1) of section 3238 of
the Insurance Law to include concurrent symptoms and side effects to
the types of conditions that cannot be denied for lack of prior
authorization.

Section two provides that this act shall take effect 90 days after
enactment.

 JUSTIFICATION :

In 2007, Chapter 451 was signed into law and required plans to
reimburse providers when the plan had already provided prior
authorization for the care. Importantly, this law also limits when a
              

plan is entitled to deny payment for surgical or invasive procedures
that are closely related and rendered at the same time as the services
that had been explicitly prior authorized. This flexibility was added
to ensure that when a provider encountered an unexpected complication
or need during a surgical procedure, it was not medically prudent to
leave an individuals' health need unaddressed during the time it took
for the health plan to be contacted and issue a separate prior
authorization. The law still reserves the plan's right to make a
medical necessity determination and simply bars from the plan from
issuing an administrative denial over the deviation from the initial
authorization.

Recently, certain vendor organizations subcontracted by health plans
regulated by New York have been denying related services when they are
not clearly pre-authorized although services do not meet the current
definition of "surgical or invasive, requiring sedation".  These
carve-out entities are denying reimbursement for medically sensitive
services, even when medically necessary, if not explicitly prior
authorized. For example, chemotherapy is prior authorized on an
outpatient basis, however, patients who arrive for chemotherapy are
often treated for related symptoms such as nausea, low platelet count,
allergic reactions, etc.  These symptoms are treated by the provider
so the individual can continue to receive chemotherapy, especially
because patients are maintaining strict regimens to fight their
particular type of cancer and/or have traveled long distances to a
hospital that provides oncology services.

Similar to the surgical/invasive procedure exception that was
initially inserted to the prior authorization law, it is not in the
patient's medical interest to leave symptoms unaddressed or delay
chemotherapy so the health plan can be contacted to issue a separate
prior authorization. This bill would expand this current exception to
ensure patients receive medically necessary services when they are in
a medically compromised state and prevent plans or their
subcontractors from delaying or denying necessary treatment on the
sole basis that they were not specifically prior authorized.

 LEGISLATIVE HISTORY :

New Bill
 FISCAL IMPLICATIONS :

None

 EFFECTIVE DATE :
Ninety days after it shall become law.