S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   2352
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 16, 2025
                                ___________
 
 Introduced  by  M.  of  A.  McDONALD, WOERNER, STECK, SEAWRIGHT, STIRPE,
   CUNNINGHAM,  RIVERA,  KELLES,  ALVAREZ,  LUPARDO,  LEMONDES,  BENDETT,
   SHRESTHA  --  Multi-Sponsored  by  --  M. of A. SIMON -- read once and
   referred to the Committee on Insurance
 
 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-
 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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD01540-01-5
              

 A. 2352                             2
 
 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)  IF THE HEALTH CARE PROFESSIONAL DOES NOT HAVE THE APPROVAL AT THE
 TIME OF THE RELEVANT EVALUATION PERIOD; AND
 A. 2352                             3
 
   (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
   (B) FAILED TO SUBSTANTIALLY PERFORM THE HEALTH CARE SERVICE;
 A. 2352                             4

   (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. 2352                             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. 2352                             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. 2352                             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.