S T A T E O F N E W Y O R K
________________________________________________________________________
859--A
2023-2024 Regular Sessions
I N A S S E M B L Y
January 11, 2023
___________
Introduced by M. of A. McDONALD, WOERNER, STECK, SEAWRIGHT, SILLITTI,
GUNTHER, STIRPE, CUNNINGHAM, RIVERA, KELLES, ALVAREZ, LUPARDO --
Multi-Sponsored by -- M. of A. SIMON -- read once and referred to the
Committee on Insurance -- recommitted to the Committee on Insurance in
accordance with Assembly Rule 3, sec. 2 -- committee discharged, bill
amended, ordered reprinted as amended and recommitted to said commit-
tee
AN ACT to amend the insurance law and the public health law, in relation
to requiring insurers and health plans to grant automatic preauthori-
zation approvals to eligible health care professionals in certain
circumstances
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subsection (a) of section 4902 of the insurance law is
amended by adding a new paragraph 15 to read as follows:
(15) ESTABLISHMENT OF AUTOMATIC PREAUTHORIZATION APPROVAL REQUIREMENTS
FOR INSURERS TO PROVIDE TO HEALTH CARE PROFESSIONALS PROVIDING HEALTH
CARE SERVICES WHICH SHALL INCLUDE THAT:
(I) AN INSURER THAT USES A PREAUTHORIZATION PROCESS FOR HEALTH CARE
SERVICES SHALL PROVIDE AN AUTOMATIC PREAUTHORIZATION APPROVAL TO A
HEALTH CARE PROFESSIONAL FOR A PARTICULAR HEALTH CARE SERVICE, AS
DEFINED UNDER THIS TITLE INCLUDING BUT NOT LIMITED TO HEALTH CARE PROCE-
DURES, TREATMENTS, SERVICES, PHARMACEUTICAL PRODUCTS, SERVICES OR DURA-
BLE MEDICAL EQUIPMENT IF, IN THE MOST RECENT SIX-MONTH EVALUATION PERI-
OD, THE INSURER HAS APPROVED NOT LESS THAN NINETY PERCENT OF THE
PREAUTHORIZATION REQUESTS SUBMITTED BY SUCH HEALTH CARE PROFESSIONAL FOR
THE PARTICULAR HEALTH CARE SERVICE. FOR THE PURPOSES OF THIS REQUIRE-
MENT, A PREAUTHORIZATION REQUEST SUBMITTED DURING THE EVALUATION PERIOD
SHALL BE CONSIDERED AND COUNTED AS A SINGLE REQUEST AND SINGLE APPROVAL
IF THE REQUEST WAS APPROVED AT ANY POINT BETWEEN THE DATE THE REQUEST
WAS SUBMITTED BY THE HEALTH CARE PROFESSIONAL AND THE FINAL DETERMI-
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02507-06-4
A. 859--A 2
NATION BY THE INSURER, INCLUDING ANY RE-REVIEW OR APPEAL PROCESS. EACH
INSURER SHALL COMPLETE ITS INITIAL EVALUATION AND ISSUE ITS DETERMI-
NATION TO EACH HEALTH CARE PROFESSIONAL IN ITS NETWORK NO LATER THAN ONE
HUNDRED EIGHTY DAYS AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH. THE
AUTOMATIC PREAUTHORIZATION APPROVAL SHALL BECOME EFFECTIVE TWO HUNDRED
TWENTY-FIVE DAYS AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH;
(II) AFTER THE INITIAL EVALUATION HAS BEEN COMPLETED THE INSURER SHALL
ANNUALLY THEREAFTER EVALUATE WHETHER A HEALTH CARE PROFESSIONAL QUALI-
FIES FOR AN AUTOMATIC PREAUTHORIZATION APPROVAL UNDER SUBPARAGRAPH (I)
OF THIS PARAGRAPH FOR ADDITIONAL HEALTH CARE SERVICES. EACH YEAR, THE
EVALUATION SHALL REVIEW PREAUTHORIZATION DETERMINATIONS MADE IN THE
FIRST SIX MONTHS OF THE YEAR. EACH INSURER SHALL ISSUE ITS DETERMINATION
TO EACH HEALTH CARE PROFESSIONAL IN ITS NETWORK NO LATER THAN NOVEMBER
FIFTEENTH TO BE EFFECTIVE JANUARY FIRST OF THE FOLLOWING YEAR;
(III) THE INSURER MAY CONTINUE THE AUTOMATIC PREAUTHORIZATION APPROVAL
UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH WITHOUT EVALUATING WHETHER THE
HEALTH CARE PROFESSIONAL QUALIFIES FOR AUTOMATIC PREAUTHORIZATION
APPROVAL FOR A PARTICULAR EVALUATION PERIOD;
(IV) A HEALTH CARE PROFESSIONAL SHALL NOT BE REQUIRED TO REQUEST AN
AUTOMATIC PREAUTHORIZATION APPROVAL TO QUALIFY FOR SUCH APPROVAL;
(V) A HEALTH CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION APPROVAL
UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH SHALL REMAIN IN EFFECT UNTIL
THE THIRTIETH CALENDAR DAY AFTER:
(A) THE DATE THE INSURER NOTIFIES THE HEALTH CARE PROFESSIONAL OF THE
INSURER'S DETERMINATION TO RESCIND THE AUTOMATIC PREAUTHORIZATION
APPROVAL PURSUANT TO SUBPARAGRAPH (VII) OF THIS PARAGRAPH IF THE HEALTH
CARE PROFESSIONAL DOES NOT APPEAL SUCH DETERMINATION; OR
(B) WHERE THE HEALTH CARE PROFESSIONAL APPEALS THE DETERMINATION, THE
DATE THE INSURER NOTIFIES THE HEALTH CARE PROFESSIONAL THAT AN INDEPEND-
ENT REVIEW ORGANIZATION HAS AFFIRMED THE INSURER'S DETERMINATION TO
RESCIND THE AUTOMATIC PREAUTHORIZATION APPROVAL;
(VI) WHERE AN INSURER DOES NOT FINALIZE A RESCISSION DETERMINATION AS
SPECIFIED IN SUBPARAGRAPH (VII) OF THIS PARAGRAPH, THE HEALTH CARE
PROFESSIONAL SHALL BE CONSIDERED TO HAVE MET THE CRITERIA TO CONTINUE TO
QUALIFY FOR THE AUTOMATIC PREAUTHORIZATION APPROVAL, WHICH SHALL REMAIN
IN EFFECT UNTIL THE FOLLOWING EVALUATION PERIOD;
(VII) AN INSURER MAY RESCIND AN AUTOMATIC PREAUTHORIZATION APPROVAL
UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH ONLY:
(A) EFFECTIVE JANUARY OF EACH YEAR;
(B) IF THE INSURER MAKES A DETERMINATION ON THE BASIS OF A RETROSPEC-
TIVE REVIEW AS SPECIFIED IN SUBPARAGRAPH (II) OF THIS PARAGRAPH FOR THE
MOST RECENT EVALUATION PERIOD THAT LESS THAN NINETY PERCENT OF THE
CLAIMS FOR THE PARTICULAR HEALTH CARE SERVICE MET THE MEDICAL NECESSITY
CRITERIA THAT WOULD HAVE BEEN USED BY THE INSURER WHEN CONDUCTING PREAU-
THORIZATION REVIEW FOR THE PARTICULAR HEALTH CARE SERVICE DURING THE
RELEVANT EVALUATION PERIOD; AND
(C) THE INSURER COMPLIES WITH ALL OTHER APPLICABLE REQUIREMENTS OF
THIS PARAGRAPH AND THE INSURER NOTIFIES THE HEALTH CARE PROFESSIONAL NOT
LESS THAN THIRTY CALENDAR DAYS BEFORE THE PROPOSED RESCISSION IS TO TAKE
EFFECT, TOGETHER WITH THE SAMPLE OF CLAIMS USED TO MAKE THE DETERMI-
NATION PURSUANT TO CLAUSE (B) OF THIS SUBPARAGRAPH AND A PLAIN LANGUAGE
EXPLANATION OF THE HEALTH CARE PROFESSIONAL'S RIGHT TO APPEAL SUCH
DETERMINATION AND INSTRUCTIONS ON HOW TO INITIATE SUCH APPEAL;
(VIII) NOTWITHSTANDING ANY CONTRARY PROVISION OF SUBPARAGRAPH (I) OF
THIS PARAGRAPH, AN INSURER MAY DENY AN AUTOMATIC PREAUTHORIZATION
APPROVAL:
A. 859--A 3
(A) IF THE HEALTH CARE PROFESSIONAL DOES NOT HAVE THE APPROVAL AT THE
TIME OF THE RELEVANT EVALUATION PERIOD; AND
(B) THE INSURER PROVIDES THE HEALTH CARE PROFESSIONAL WITH ACTUAL
STATISTICS AND DATA FOR THE RELEVANT PREAUTHORIZATION REQUEST EVALUATION
PERIOD AND DETAILED INFORMATION SUFFICIENT TO DEMONSTRATE THAT THE
HEALTH CARE PROFESSIONAL DOES NOT MEET THE CRITERIA FOR AN AUTOMATIC
PREAUTHORIZATION APPROVAL PURSUANT TO SUBPARAGRAPH (I) OF THIS PARAGRAPH
FOR THE PARTICULAR HEALTH CARE SERVICE;
(IX) AFTER A FINAL DETERMINATION OR REVIEW AFFIRMING THE RESCISSION OR
DENIAL OF AN AUTOMATIC PREAUTHORIZATION APPROVAL FOR A SPECIFIC HEALTH
CARE SERVICE UNDER THIS PARAGRAPH, A HEALTH CARE PROFESSIONAL SHALL BE
ELIGIBLE FOR CONSIDERATION OF SUCH APPROVAL FOR THE SAME HEALTH CARE
SERVICE AFTER THE EVALUATION PERIOD FOLLOWING THE EVALUATION PERIOD
WHICH FORMED THE BASIS OF THE RESCISSION OR DENIAL OF SUCH APPROVAL;
(X) THE INSURER SHALL, NOT LATER THAN FIVE BUSINESS DAYS AFTER DETER-
MINING THAT A HEALTH CARE PROFESSIONAL QUALIFIES FOR AN AUTOMATIC PREAU-
THORIZATION APPROVAL PURSUANT TO SUBPARAGRAPH (I) OF THIS PARAGRAPH,
PROVIDE TO A HEALTH CARE PROFESSIONAL A NOTICE THAT SHALL INCLUDE:
(A) A STATEMENT THAT THE HEALTH CARE PROFESSIONAL QUALIFIES FOR AN
AUTOMATIC PREAUTHORIZATION APPROVAL PURSUANT TO THIS PARAGRAPH;
(B) A DESCRIPTION OF THE HEALTH CARE SERVICES TO WHICH SUCH AUTOMATIC
PREAUTHORIZATION APPLIES; AND
(C) A STATEMENT OF THE DURATION THAT SUCH AUTOMATIC APPROVAL SHALL
REMAIN IN EFFECT;
(XI) WHEN THE HEALTH CARE PROFESSIONAL SUBMITS A PREAUTHORIZATION
REQUEST FOR A HEALTH CARE SERVICE FOR WHICH THE HEALTH CARE PROFESSIONAL
QUALIFIES FOR AN AUTOMATIC PREAUTHORIZATION APPROVAL UNDER SUBPARAGRAPH
(I) OF THIS PARAGRAPH, THE INSURER SHALL PROMPTLY ISSUE AN AUTOMATIC
PREAUTHORIZATION APPROVAL FOR SUCH HEALTH CARE SERVICE;
(XII) NOTHING IN THIS PARAGRAPH MAY BE CONSTRUED TO:
(A) AUTHORIZE A HEALTH CARE PROFESSIONAL TO PROVIDE A HEALTH CARE
SERVICE OUTSIDE THE SCOPE OF SUCH HEALTH CARE PROFESSIONAL'S APPLICABLE
LICENSE; OR
(B) PROHIBIT A HEALTH INSURER FROM PERFORMING A RETROSPECTIVE REVIEW
OF THE HEALTH CARE SERVICE PURSUANT TO SECTION FORTY-NINE HUNDRED THREE
OF THIS TITLE;
(XIII) WHEN A HEALTH CARE PROFESSIONAL PROVIDES A HEALTH CARE SERVICE
COVERED BY THE HEALTH CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION
APPROVAL, THE SERVICE IS DEEMED MEDICALLY NECESSARY BY VIRTUE OF THE
AUTOMATIC PREAUTHORIZATION APPROVAL. FOR EVERY CLAIM SUBMITTED BY A
HEALTH CARE PROFESSIONAL FOR SUCH SERVICE, EACH INSURER SHALL PROMPTLY
PAY THE FULL PAYMENT TO THE HEALTH CARE PROFESSIONAL. AN INSURER IS
PROHIBITED FROM DENYING, WITHHOLDING, OR REDUCING PAYMENT TO A HEALTH
CARE PROFESSIONAL FOR SUCH HEALTH CARE SERVICE. AN INSURER MAY NOT
RETROACTIVELY DENY, REDUCE, OR RECOUP PAYMENT FROM A HEALTH CARE PROFES-
SIONAL FOR SUCH HEALTH CARE SERVICE FOR REASONS RELATED TO MEDICAL
NECESSITY OR APPROPRIATENESS OF CARE;
(XIV) AN INSURER MAY NOT RETROACTIVELY DENY, REDUCE, OR RECOUP PAYMENT
FROM A HEALTH CARE PROFESSIONAL FOR A HEALTH CARE SERVICE FOR WHICH THE
HEALTH CARE PROFESSIONAL HAS QUALIFIED FOR AN AUTOMATIC PREAUTHORIZATION
APPROVAL UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH UNLESS THE INSURER HAS
PROVEN THAT THE HEALTH CARE PROFESSIONAL:
(A) KNOWINGLY AND MATERIALLY MISREPRESENTED THE HEALTH CARE SERVICE IN
A REQUEST FOR PREAUTHORIZATION OR PAYMENT SUBMITTED TO THE INSURER WITH
THE SPECIFIC INTENT TO DECEIVE AND OBTAIN AN UNLAWFUL PAYMENT FROM THE
INSURER; OR
A. 859--A 4
(B) FAILED TO SUBSTANTIALLY PERFORM THE HEALTH CARE SERVICE;
(XV) AN INSURER MAY NOT RETROACTIVELY DENY, REDUCE OR RECOUP PAYMENT
FROM A HEALTH CARE PROFESSIONAL FOR A HEALTH CARE SERVICE FOR WHICH THE
HEALTH CARE PROFESSIONAL HAS QUALIFIED FOR AN AUTOMATIC PREAUTHORIZATION
APPROVAL SOLELY ON THE BASIS OF THE RESCISSION OF THE HEALTH CARE
PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION APPROVAL. NOTHING HEREIN SHALL
LIMIT A HEALTH CARE PROFESSIONAL'S ABILITY TO FILE A COMPLAINT WITH THE
DEPARTMENT;
(XVI) THE INSURER SHALL MAKE AVAILABLE AND SUBMIT TO THE SUPERINTEN-
DENT, AT THE SUPERINTENDENT'S REQUEST, DOCUMENTATION THAT DESCRIBES THE
INSURER'S PROCESS FOR:
(A) DETERMINING THE SPECIFIC HEALTH CARE SERVICE OR SERVICES FOR WHICH
AN INDIVIDUAL HEALTH CARE PROFESSIONAL IS GRANTED AN AUTOMATIC PREAU-
THORIZATION APPROVAL; AND
(B) ANY OTHER ACTIVITY, POLICY, DECISION, OR DETERMINATION RELATED TO
AUTOMATIC PREAUTHORIZATION APPROVALS; AND
(XVII) THE SUPERINTENDENT SHALL PROMULGATE REGULATIONS TO IMPLEMENT
THE REQUIREMENTS OF THIS SECTION AND ESTABLISH ADDITIONAL MINIMUM STAND-
ARDS AS APPROPRIATE.
§ 2. Subdivision 1 of section 4902 of the public health law is amended
by adding a new paragraph (m) to read as follows:
(M) ESTABLISHMENT OF AUTOMATIC PREAUTHORIZATION APPROVAL REQUIREMENTS
FOR HEALTH CARE PLANS TO PROVIDE TO HEALTH CARE PROFESSIONALS PROVIDING
CERTAIN HEALTH CARE SERVICES WHICH SHALL INCLUDE THAT:
(I) A HEALTH CARE PLAN THAT USES A PREAUTHORIZATION PROCESS FOR HEALTH
CARE SERVICES SHALL PROVIDE AN AUTOMATIC PREAUTHORIZATION APPROVAL TO A
HEALTH CARE PROFESSIONAL FOR A PARTICULAR HEALTH CARE SERVICE IF, AS
DEFINED UNDER THIS TITLE INCLUDING BUT NOT LIMITED TO HEALTH CARE PROCE-
DURES, TREATMENTS, SERVICES, PHARMACEUTICAL PRODUCTS, SERVICES OR DURA-
BLE MEDICAL EQUIPMENT, IN THE MOST RECENT SIX-MONTH EVALUATION PERIOD,
THE HEALTH CARE PLAN HAS APPROVED NOT LESS THAN NINETY PERCENT OF THE
PREAUTHORIZATION REQUESTS SUBMITTED BY SUCH HEALTH CARE PROFESSIONAL FOR
THE PARTICULAR HEALTH CARE SERVICE. FOR THE PURPOSES OF THIS REQUIRE-
MENT, A PREAUTHORIZATION REQUEST SUBMITTED DURING THE EVALUATION PERIOD
SHALL BE CONSIDERED AND COUNTED AS A SINGLE REQUEST AND SINGLE APPROVAL
IF THE REQUEST WAS APPROVED AT ANY POINT BETWEEN THE DATE THE REQUEST
WAS SUBMITTED BY THE HEALTH CARE PROFESSIONAL AND THE FINAL DETERMI-
NATION BY THE HEALTH CARE PLAN, INCLUDING ANY RE-REVIEW OR APPEAL PROC-
ESS. EACH INSURER SHALL COMPLETE ITS INITIAL EVALUATION AND ISSUE ITS
DETERMINATION TO EACH HEALTH CARE PROFESSIONAL IN ITS NETWORK NO LATER
THAN ONE HUNDRED EIGHTY DAYS AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH.
THE AUTOMATIC PREAUTHORIZATION APPROVAL SHALL BECOME EFFECTIVE TWO
HUNDRED TWENTY-FIVE DAYS AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH;
(II) AFTER THE INITIAL EVALUATION HAS BEEN COMPLETED THE HEALTH CARE
PLAN SHALL ANNUALLY THEREAFTER EVALUATE WHETHER A HEALTH CARE PROFES-
SIONAL QUALIFIES FOR AN AUTOMATIC PREAUTHORIZATION APPROVAL UNDER
SUBPARAGRAPH (I) OF THIS PARAGRAPH FOR ADDITIONAL HEALTH CARE SERVICES.
EACH YEAR, THE EVALUATION SHALL REVIEW PREAUTHORIZATION DETERMINATIONS
MADE IN THE FIRST SIX MONTHS OF THE YEAR. EACH HEALTH CARE PLAN SHALL
ISSUE ITS DETERMINATION TO EACH HEALTH CARE PROFESSIONAL IN ITS NETWORK
NO LATER THAN NOVEMBER FIFTEENTH TO BE EFFECTIVE JANUARY FIRST OF THE
FOLLOWING YEAR;
(III) THE HEALTH CARE PLAN MAY CONTINUE THE AUTOMATIC PREAUTHORIZATION
APPROVAL UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH WITHOUT EVALUATING
WHETHER THE HEALTH CARE PROFESSIONAL QUALIFIES FOR THE AUTOMATIC PREAU-
THORIZATION APPROVAL FOR A PARTICULAR EVALUATION PERIOD;
A. 859--A 5
(IV) A HEALTH CARE PROFESSIONAL SHALL NOT BE REQUIRED TO REQUEST AN
AUTOMATIC PREAUTHORIZATION APPROVAL TO QUALIFY FOR SUCH APPROVAL;
(V) A HEALTH CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION APPROVAL
UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH SHALL REMAIN IN EFFECT UNTIL
THE THIRTIETH CALENDAR DAY AFTER:
(A) THE DATE THE HEALTH CARE PLAN NOTIFIES THE HEALTH CARE PROFES-
SIONAL OF THE HEALTH CARE PLAN'S DETERMINATION TO RESCIND THE AUTOMATIC
PREAUTHORIZATION APPROVAL PURSUANT TO SUBPARAGRAPH (VII) OF THIS PARA-
GRAPH IF THE HEALTH CARE PROFESSIONAL DOES NOT APPEAL SUCH DETERMI-
NATION; OR
(B) WHERE THE HEALTH CARE PROFESSIONAL APPEALS THE DETERMINATION, THE
DATE THE HEALTH CARE PLAN NOTIFIES THE HEALTH CARE PROFESSIONAL THAT AN
INDEPENDENT REVIEW ORGANIZATION HAS AFFIRMED THE HEALTH CARE PLAN'S
DETERMINATION TO RESCIND THE AUTOMATIC PREAUTHORIZATION APPROVAL;
(VI) WHERE A HEALTH CARE PLAN DOES NOT FINALIZE A RESCISSION DETERMI-
NATION AS SPECIFIED IN SUBPARAGRAPH (VII) OF THIS PARAGRAPH, THE HEALTH
CARE PROFESSIONAL SHALL BE CONSIDERED TO HAVE MET THE CRITERIA TO
CONTINUE TO QUALIFY FOR THE AUTOMATIC PREAUTHORIZATION APPROVAL, WHICH
SHALL REMAIN IN EFFECT UNTIL THE FOLLOWING EVALUATION PERIOD;
(VII) A HEALTH CARE PLAN MAY RESCIND AN EXEMPTION FROM PREAUTHORI-
ZATION REQUIREMENTS UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH ONLY:
(A) EFFECTIVE JANUARY EACH YEAR;
(B) IF THE HEALTH CARE PLAN MAKES A DETERMINATION ON THE BASIS OF A
RETROSPECTIVE REVIEW AS SPECIFIED IN SUBPARAGRAPH (II) OF THIS PARAGRAPH
FOR THE MOST RECENT EVALUATION PERIOD THAT LESS THAN NINETY PERCENT OF
THE CLAIMS FOR THE PARTICULAR HEALTH CARE SERVICE MET THE MEDICAL NECES-
SITY CRITERIA THAT WOULD HAVE BEEN USED BY THE HEALTH CARE PLAN WHEN
CONDUCTING PREAUTHORIZATION REVIEW FOR THE PARTICULAR HEALTH CARE
SERVICE DURING THE RELEVANT EVALUATION PERIOD; AND
(C) THE HEALTH CARE PLAN COMPLIES WITH ALL OTHER APPLICABLE REQUIRE-
MENTS OF THIS PARAGRAPH AND THE HEALTH CARE PLAN NOTIFIES THE HEALTH
CARE PROFESSIONAL NOT LESS THAN THIRTY CALENDAR DAYS BEFORE THE PROPOSED
RESCISSION IS TO TAKE EFFECT, TOGETHER WITH THE SAMPLE OF CLAIMS USED TO
MAKE THE DETERMINATION PURSUANT TO CLAUSE (B) OF THIS SUBPARAGRAPH AND A
PLAIN LANGUAGE EXPLANATION OF THE HEALTH CARE PROFESSIONAL'S RIGHT TO
APPEAL SUCH DETERMINATION AND INSTRUCTIONS ON HOW TO INITIATE SUCH
APPEAL;
(VIII) NOTWITHSTANDING ANY CONTRARY PROVISION OF SUBPARAGRAPH (I) OF
THIS PARAGRAPH, A HEALTH CARE PLAN MAY DENY AN AUTOMATIC PREAUTHORI-
ZATION APPROVAL:
(A) IF THE HEALTH CARE PROFESSIONAL DOES NOT HAVE THE APPROVAL AT THE
TIME OF THE RELEVANT EVALUATION PERIOD; AND
(B) THE HEALTH CARE PLAN PROVIDES THE HEALTH CARE PROFESSIONAL WITH
ACTUAL STATISTICS AND DATA FOR THE RELEVANT PREAUTHORIZATION REQUEST
EVALUATION PERIOD AND DETAILED INFORMATION SUFFICIENT TO DEMONSTRATE
THAT THE HEALTH CARE PROFESSIONAL DOES NOT MEET THE CRITERIA FOR AN
AUTOMATIC PREAUTHORIZATION APPROVAL PURSUANT TO SUBPARAGRAPH (I) OF THIS
PARAGRAPH FOR THE PARTICULAR HEALTH CARE SERVICE;
(IX) AFTER A FINAL DETERMINATION OR REVIEW AFFIRMING THE RESCISSION OR
DENIAL OF AN AUTOMATIC PREAUTHORIZATION APPROVAL FOR A SPECIFIC HEALTH
CARE SERVICE UNDER THIS PARAGRAPH, A HEALTH CARE PROFESSIONAL SHALL BE
ELIGIBLE FOR CONSIDERATION OF SUCH APPROVAL FOR THE SAME HEALTH CARE
SERVICE AFTER THE EVALUATION PERIOD FOLLOWING THE EVALUATION PERIOD
WHICH FORMED THE BASIS OF THE RESCISSION OR DENIAL OF SUCH APPROVAL;
(X) THE HEALTH CARE PLAN SHALL, NOT LATER THAN FIVE BUSINESS DAYS
AFTER DETERMINING THAT A HEALTH CARE PROFESSIONAL QUALIFIES FOR AN AUTO-
A. 859--A 6
MATIC PREAUTHORIZATION APPROVAL PURSUANT TO SUBPARAGRAPH (I) OF THIS
PARAGRAPH, PROVIDE TO A HEALTH CARE PROFESSIONAL A NOTICE THAT SHALL
INCLUDE:
(A) A STATEMENT THAT THE HEALTH CARE PROFESSIONAL QUALIFIES FOR AN
AUTOMATIC PREAUTHORIZATION APPROVAL PURSUANT TO THIS PARAGRAPH;
(B) A DESCRIPTION OF THE HEALTH CARE SERVICES TO WHICH SUCH AUTOMATIC
PREAUTHORIZATION APPROVAL APPLIES; AND
(C) A STATEMENT OF THE DURATION THAT SUCH AUTOMATIC APPROVAL SHALL
REMAIN IN EFFECT;
(XI) WHEN THE HEALTH CARE PROFESSIONAL SUBMITS A PREAUTHORIZATION
REQUEST FOR A HEALTH CARE SERVICE FOR WHICH THE HEALTH CARE PROFESSIONAL
QUALIFIES FOR AN AUTOMATIC PREAUTHORIZATION APPROVAL UNDER SUBPARAGRAPH
(I) OF THIS PARAGRAPH, THE HEALTH CARE PLAN SHALL PROMPTLY ISSUE AN
AUTOMATIC PREAUTHORIZATION APPROVAL FOR SUCH HEALTH CARE SERVICE;
(XII) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO:
(A) AUTHORIZE A HEALTH CARE PROFESSIONAL TO PROVIDE A HEALTH CARE
SERVICE OUTSIDE THE SCOPE OF SUCH HEALTH CARE PROFESSIONAL'S APPLICABLE
LICENSE; OR
(B) PROHIBIT A HEALTH CARE PLAN FROM PERFORMING A RETROSPECTIVE REVIEW
OF THE HEALTH CARE SERVICE PURSUANT TO SECTION FORTY-NINE HUNDRED THREE
OF THIS TITLE;
(XIII) WHEN A HEALTH CARE PROFESSIONAL PROVIDES A HEALTH CARE SERVICE
COVERED BY THE HEALTH CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION
APPROVAL, THE SERVICE IS DEEMED MEDICALLY NECESSARY BY VIRTUE OF THE
AUTOMATIC PREAUTHORIZATION APPROVAL. FOR EVERY CLAIM SUBMITTED BY A
HEALTH CARE PROFESSIONAL FOR SUCH SERVICE, EACH HEALTH CARE PLAN SHALL
PROMPTLY PAY THE FULL PAYMENT TO THE HEALTH CARE PROFESSIONAL. A HEALTH
CARE PLAN IS PROHIBITED FROM DENYING, WITHHOLDING, OR REDUCING PAYMENT
TO A HEALTH CARE PROFESSIONAL FOR SUCH HEALTH CARE SERVICE. A HEALTH
CARE PLAN MAY NOT RETROACTIVELY DENY, REDUCE, OR RECOUP PAYMENT FROM A
HEALTH CARE PROFESSIONAL FOR SUCH HEALTH CARE SERVICE FOR REASONS
RELATED TO MEDICAL NECESSITY OR APPROPRIATENESS OF CARE;
(XIV) A HEALTH CARE PLAN MAY NOT RETROACTIVELY DENY, REDUCE, OR RECOUP
PAYMENT FROM A HEALTH CARE PROFESSIONAL FOR A HEALTH CARE SERVICE FOR
WHICH THE HEALTH CARE PROFESSIONAL HAS QUALIFIED FOR AN AUTOMATIC PREAU-
THORIZATION APPROVAL UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH UNLESS THE
HEALTH CARE PLAN HAS PROVEN THAT THE HEALTH CARE PROFESSIONAL:
(A) KNOWINGLY AND MATERIALLY MISREPRESENTED THE HEALTH CARE SERVICE IN
A REQUEST FOR PREAUTHORIZATION OR PAYMENT SUBMITTED TO THE HEALTH CARE
PLAN WITH THE SPECIFIC INTENT TO DECEIVE AND OBTAIN AN UNLAWFUL PAYMENT
FROM THE HEALTH CARE PLAN; OR
(B) FAILED TO SUBSTANTIALLY PERFORM THE HEALTH CARE SERVICE;
(XV) A HEALTH CARE PLAN MAY NOT RETROACTIVELY DENY, REDUCE OR RECOUP
PAYMENT FROM A HEALTH CARE PROFESSIONAL FOR A HEALTH CARE SERVICE FOR
WHICH THE HEALTH CARE PROFESSIONAL HAS QUALIFIED FOR AN AUTOMATIC PREAU-
THORIZATION APPROVAL SOLELY ON THE BASIS OF THE RESCISSION OF THE HEALTH
CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION APPROVAL. NOTHING HEREIN
SHALL LIMIT A HEALTH CARE PROFESSIONAL'S ABILITY TO FILE A COMPLAINT
WITH THE DEPARTMENT;
(XVI) THE HEALTH CARE PLAN SHALL MAKE AVAILABLE AND SUBMIT TO THE
COMMISSIONER, AT THE COMMISSIONER'S REQUEST, DOCUMENTATION THAT
DESCRIBES THE HEALTH CARE PLAN'S PROCESS FOR:
(A) DETERMINING THE SPECIFIC HEALTH CARE SERVICE OR SERVICES FOR WHICH
AN INDIVIDUAL HEALTH CARE PROFESSIONAL IS GRANTED AN AUTOMATIC PREAU-
THORIZATION APPROVAL; AND
A. 859--A 7
(B) ANY OTHER ACTIVITY, POLICY, DECISION, OR DETERMINATION RELATED TO
AUTOMATIC PREAUTHORIZATION APPROVALS; AND
(XVII) THE COMMISSIONER, IN CONSULTATION WITH THE SUPERINTENDENT,
SHALL PROMULGATE REGULATIONS TO IMPLEMENT THE REQUIREMENTS OF THIS
SECTION AND ESTABLISH ADDITIONAL MINIMUM STANDARDS AS APPROPRIATE.
§ 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.