§ 4406-d. Health care professional applications and terminations. 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 developing its
qualification requirements. A health care plan shall complete review of
the health care professional's application to participate 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
application 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 necessary 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.

(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
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 health care plan. A
health care professional shall only be eligible for provisional
credentialing 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 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
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) A newly-licensed physician, a physician who has recently relocated
to this state from another state and has not previously practiced in
this state, or a physician who has changed his or her corporate
relationship such that it results in the issuance of a new tax
identification number under which such physician's services are billed
for and who previously had a participation contract with the health care
plan immediately prior to the event that changed his or her corporate
relationship, who becomes employed by a general hospital or diagnostic
and treatment center licensed pursuant to article twenty-eight of this
chapter, or a facility licensed under article sixteen, article
thirty-one or article thirty-two of the mental hygiene law which has a
participating provider contract with a health care plan, and whose other
employed physicians participate in the in-network portion of a health
care plan's network, shall be deemed "provisionally credentialed" and
may participate in the in-network portion of a health care plan's
network during this time period upon: (i) the health care plan's receipt
of the hospital and physician's completed sections of the insurer's
credentialing application; and (ii) the health care plan being notified
in writing that the health care professional has been granted hospital
privileges pursuant to the requirements of section twenty-eight hundred
five-k of this chapter. However, a provisionally credentialed physician
shall not be designated as an enrollee's primary care physician until
such time as the physician has been fully credentialed by the health
care plan. Notwithstanding any other provision of law, a health care
plan shall not be required to make any payments to the licensed general
hospital, the licensed diagnostic and treatment center or a facility
licensed under article sixteen, article thirty-one or article thirty-two
of the mental hygiene law for the service provided by a provisionally
credentialed physician, until and unless the physician is fully
credentialed by the health care plan, provided, however, that upon being
fully credentialed, the licensed general hospital, the licensed
diagnostic and treatment center or a facility licensed under article
sixteen, article thirty-one or article thirty-two of the mental hygiene
law shall be paid for all services provided by the physician for up to
sixty days after submission of the completed application that the
credentialed physician provided to the health care plan's insureds from
the date the physician fully met the requirements to be provisionally
credentialed pursuant to this paragraph. Should the application
ultimately be denied by the health care plan, the health care plan shall
not be liable for any payment to the licensed general hospital, the
licensed diagnostic and treatment center or a facility licensed under
article sixteen, article thirty-one or article thirty-two of the mental
hygiene law for the services provided by the provisionally credentialed
health care professional; and the licensed general hospital, the
licensed diagnostic and treatment center or a facility licensed under
article sixteen, article thirty-one or article thirty-two of the mental
hygiene law shall not pursue reimbursement from the insured, except to
collect the copayment or coinsurance or deductible amount that otherwise
would have been payable had the insured received services from a health
care professional participating in the in-network portion of a health
care plan's network.

2. (a) A health care plan shall not terminate a contract with a health
care professional unless the health care plan provides to the health
care professional a written explanation of the reasons for the proposed
contract termination and an opportunity for a review or hearing as
hereinafter provided. This section shall not apply in cases involving
imminent harm to patient care, a determination of fraud, or a final
disciplinary action by a state licensing board or other governmental
agency that impairs the health care professional's ability to practice.

(b) The notice of the proposed contract termination provided by the
health care plan to the health care professional shall include:

(i) the reasons for the proposed action;

(ii) notice that the health care professional has the right to request
a hearing or review, at the professional's discretion, before a panel
appointed by the health care plan;

(iii) a time limit of not less than thirty days within which a health
care professional may request a hearing; and

(iv) a time limit for a hearing date which must be held within thirty
days after the date of receipt of a request for a hearing.

(c) The hearing panel shall be comprised of three persons appointed by
the health care plan. At least one person on such panel shall be a
clinical peer in the same discipline and the same or similar specialty
as the health care professional under review. The hearing panel may
consist of more than three persons, provided however that the number of
clinical peers on such panel shall constitute one-third or more of the
total membership of the panel.

(d) The hearing panel shall render a decision on the proposed action
in a timely manner. Such decision shall include reinstatement of the
health care professional by the health care plan, provisional
reinstatement subject to conditions set forth by the health care plan or
termination of the health care professional. Such decision shall be
provided in writing to the health care professional.

(e) A decision by the hearing panel to terminate a health care
professional shall be effective not less than thirty days after the
receipt by the health care professional of the hearing panel's decision;
provided, however, that the provisions of paragraph (e) of subdivision
six of section four thousand four hundred three of this article shall
apply to such termination.

(f) In no event shall termination be effective earlier than sixty days
from the receipt of the notice of termination.

3. Either party to a contract may exercise a right of non-renewal at
the expiration of the contract period set forth therein or, for a
contract without a specific expiration date, on each January first
occurring after the contract has been in effect for at least one year,
upon sixty days notice to the other party; provided, however, that any
non-renewal shall not constitute a termination for purposes of this
section.

4. A health care plan shall develop and implement policies and
procedures to ensure that health care professionals are regularly
informed of information maintained by the health care plan to evaluate
the performance or practice of the health care professional. The health
care plan shall consult with health care professionals in developing
methodologies to collect and analyze health care professional profiling
data. Health care plans shall provide any such information and profiling
data and analysis to health care professionals. Such information, data
or analysis shall be provided on a periodic basis appropriate to the
nature and amount of data and the volume and scope of services provided.
Any profiling data used to evaluate the performance or practice of a
health care professional shall be measured against stated criteria and
an appropriate group of health care professionals using similar
treatment modalities serving a comparable patient population. Upon
presentation of such information or data, each health care professional
shall be given the opportunity to discuss the unique nature of the
health care professional's patient population which may have a bearing
on the health care professional's profile and to work cooperatively with
the health care plan to improve performance.

5. No health care plan shall terminate a contract or employment, or
refuse to renew a contract, solely because a health care provider has:

(a) advocated on behalf of an enrollee;

(b) filed a complaint against the health care plan;

(c) appealed a decision of the health care plan;

(d) provided information or filed a report pursuant to section
forty-four hundred six-c of this article; or

(e) requested a hearing or review pursuant to this section.

6. Except as provided herein, no contract or agreement between a
health care plan and a health care professional shall contain any
provision which shall supersede or impair a health care professional's
right to notice of reasons for termination and the opportunity for a
hearing or review concerning such termination.

7. Any contract provision in violation of this section shall be deemed
to be void and unenforceable.

8. For purposes of this section, "health care plan" shall mean a
health maintenance organization licensed pursuant to article forty-three
of the insurance law or certified pursuant to this article or an
independent practice association certified or recognized pursuant to
this article.

9. For purposes of this section, "health care professional" shall mean
a health care professional licensed, registered or certified pursuant to
title eight of the education law.