S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   3077
 
                        2019-2020 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 28, 2019
                                ___________
 
 Introduced  by  M.  of A. GOTTFRIED, CAHILL, ENGLEBRIGHT, GALEF, JAFFEE,
   OTIS, STECK, D'URSO -- Multi-Sponsored by -- M. of A.  ABBATE,  AUBRY,
   CARROLL,  COLTON,  COOK,  CYMBROWITZ,  DINOWITZ, ORTIZ, PAULIN, PERRY,
   PRETLOW, RAMOS, RIVERA, TITUS -- read once and referred to the Commit-
   tee 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 425 of the laws of 2016, 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  sixty  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 because of
 a failure of a third party to provide necessary documentation.  In  such
 instances where additional time is necessary because of a lack of neces-
 sary documentation, a health plan shall make every effort to obtain such
 information  as  soon  as  possible and shall make a final determination
 within twenty-one days of receiving the necessary documentation.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD03362-01-9
              

 A. 3077                             2
 
   (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  sixty  days   of
 submission  of a completed application pursuant to paragraph (a) of this
 subdivision, the health care professional shall be deemed "provisionally
 credentialed" and may participate  in  the  in-network  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 creden-
 tialed. The  network  participation  for  a  provisionally  credentialed
 health  care  professional shall begin on the day following the sixtieth
 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  creden-
 tialing  if the group practice of health care professionals notifies the
 health care plan in writing that, should the application  ultimately  be
 denied,  the  health  care professional or the group practice: (i) shall
 refund any payments made by the health care plan for in-network 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  thou-
 sand  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  credentialed;  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
 FINANCIAL SERVICES, 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, INCLUDING CREDENTIALING AND RE-CREDENTIAL-
 ING  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
 FINANCIAL SERVICES, 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.
   (E)  THE  COMMISSIONER,  IN  CONSULTATION  WITH  THE SUPERINTENDENT OF
 FINANCIAL SERVICES, AND REPRESENTATIVES OF HEALTH CARE PLANS,  HOSPITALS

 A. 3077                             3
 
 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  AND  THE  STATE  CHILD HEALTH PLUS PROGRAM ARE ADEQUATELY
 REFLECTED ON THE HEALTH CARE PROFESSIONAL APPLICATION AND RE-CREDENTIAL-
 ING 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.
   § 2. Subsection (a) of section 4803 of the insurance law,  as  amended
 by chapter 425 of the laws of 2016, 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 sixty days of receiving a health care professional'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 because of a failure of a third party to provide necessary
 documentation.  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 and shall
 make a final determination  within  twenty-one  days  of  receiving  the
 necessary  documentation.  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  sixty  days of submission of a
 completed application 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;

 A. 3077                             4
 
 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. The network participation for
 a provisionally credentialed health care professional shall begin on the
 day  following  the sixtieth 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  profes-
 sionals  notifies  the  insurer  in writing that, should the application
 ultimately be denied, the health care professional or  the  group  prac-
 tice:  (A)  shall refund any payments made by the insurer for in-network
 services provided by the provisionally credentialed health care  profes-
 sional  that  exceed  any  out-of-network  benefits  payable  under  the
 insured's contract with the insurer; and (B) shall not pursue reimburse-
 ment 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. 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 professional 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, INCLUDING CREDENTIALING AND RE-CREDENTIAL-
 ING 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  AND  THE  STATE  CHILD HEALTH PLUS PROGRAM ARE ADEQUATELY
 REFLECTED ON THE HEALTH CARE PROFESSIONAL APPLICATION AND RE-CREDENTIAL-
 ING FORMS.

 A. 3077                             5
 
   (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.
   § 3. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.