senate Bill S5256

Regulates the scope, manner and performance of review of claims by utilization review agents

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Bill Status


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor
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actions

  • 15 / May / 2013
    • REFERRED TO HEALTH
  • 04 / Jun / 2013
    • 1ST REPORT CAL.1126
  • 05 / Jun / 2013
    • 2ND REPORT CAL.
  • 10 / Jun / 2013
    • ADVANCED TO THIRD READING
  • 21 / Jun / 2013
    • COMMITTED TO RULES
  • 08 / Jan / 2014
    • REFERRED TO HEALTH

Summary

Regulates the scope, manner and performance of review of claims by utilization review agents.

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Bill Details

Versions:
S5256
Legislative Cycle:
2013-2014
Current Committee:
Senate Health
Law Section:
Public Health Law
Laws Affected:
Amd §§4903, 4905 & 4914, Pub Health L; amd §§4903, 4905 & 4914, Ins L

Votes

14
0
14
Aye
0
Nay
3
aye with reservations
0
absent
0
excused
0
abstained
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Sponsor Memo

BILL NUMBER:S5256

TITLE OF BILL: An act to amend the public health law and the
insurance law, in relation to approvals by a utilization review agent

PURPOSE:

This bill amends the public health and insurance laws related to
utilization review and external appeals.

SUMMARY OF PROVISIONS:

Section 1 amends of § 4903 of the public health law to ensure that the
failure of a utilization review agent to make a determination shall be
deemed an approved claim.

Section 2 adds a new paragraph (b) of Subdivision 5 of § 4905 of the
public health law to require that utilization review agents
substantiate pre-authorizations in writing, which may be electronic.

Sections 3 amends § 4914 of the public health law to extend the
external appeal provider timeframe from 45 days to 4 months in order
to conform with recent changes to related patient timeframes.

Sections 4, 5 and 6 make the same changes as Sections 1, 2 and 3 of
the bill in the insurance law.

Section 7 - Provides for an effective date of 7/1/14.

JUSTIFICATION:

This bill is intended to address certain health plan practices that
result in unfair and unilateral reductions of payments and claims
denials. This bill strikes a balance, as it preserves all health plan
rights to review medical necessity, utilization of services, and
claims payment processing but in a manner that provides fairness to
providers and a remedy when certain utilization reviews are misapplied
by health plans.

New York State law establishes timeframes for utilization review
agents to decide whether to pay a claim. If the deadline is missed,
the claim is considered to have received an adverse determination,
i.e., payment is denied. At that point, the burden is on the provider
who must expend time and additional resources appealing the plan's
silence. Sections 1 and 4 of this bill specify that plan silence, in
response to a submitted claim, is an approved claim rather than a
denied claim.

Sections 2 and 5 of the bill require utilization review agents to
substantiate pre-authorizations in writing. Chapter 451 of 2007
required a managed care organization to pay for care that it
pre-authorized (with limited exceptions). However, there is no
requirement that pre-authorizations be provided in writing. In many
cases, providers receive the pre-authorization verbally. This section
requires verbal pre-authorizations to be confirmed in writing by
email, fax or posting on a website to avoid confusion and extra
administrative follow-up.


Sections 3 and 6 of the bill conform and harmonize the timeframes for
providers and patients/patients' designees to submit external appeals.
Legislation was enacted in 2011 that codified New York's external
appeal law with the standards in the Patient Protection and Affordable
Care Act. The timeframe for patients or patients' designees to submit
an appeal to the Department of Financial Services was extended from 45
days to four months. Providers' timeframe for an external appeal
remains at 45 days and this legislation provides conforming time
frames for patients and providers.

LEGISLATIVE HISTORY:

New bill.

FISCAL IMPLICATIONS:

None.

EFFECTIVE DATE:

This act shall take effect on July 1, 2014.

view bill text
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  5256

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                              May 15, 2013
                               ___________

Introduced  by  Sen.  HANNON -- read twice and ordered printed, and when
  printed to be committed to the Committee on Health

AN ACT to amend the public health law and the insurance law, in relation
  to approvals by a utilization review agent

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1. Subdivision 7 of section 4903 of the public health law, as
added by chapter 586 of the laws of 1998, is amended to read as follows:
  7. Failure by the utilization review agent  to  make  a  determination
within the time periods prescribed in this section shall be deemed to be
an  [adverse  determination  subject to appeal pursuant to section forty
nine hundred four of this title] APPROVAL.
  S 2. The opening paragraph of subdivision 5 of  section  4905  of  the
public health law is designated paragraph (a) and a new paragraph (b) is
added to read as follows:
  (B)  WHENEVER A UTILIZATION REVIEW AGENT MAKES A VERBAL REPRESENTATION
REGARDING PREAUTHORIZATION OR APPROVAL,  THE  UTILIZATION  REVIEW  AGENT
SHALL  IMMEDIATELY,  BUT  NOT LATER THAN WITHIN ONE BUSINESS DAY; SUPPLY
THE PROVIDER WITH A WRITTEN CONFIRMATION OF THE APPROVAL BY EITHER:
  (I) SENDING A COPY OF SUCH APPROVAL  THROUGH  ELECTRONIC  MAIL  TO  AN
ADDRESS SPECIFIED BY THE PROVIDER;
  (II) SENDING A COPY OF SUCH APPROVAL THROUGH FACSIMILE TRANSMISSION TO
A NUMBER SPECIFIED BY THE PROVIDER; OR
  (III)  POSTING  A  COPY  OF SUCH APPROVAL ON A SPECIFIC WEBPAGE OF THE
INSURER'S WEBSITE TO WHICH THE PROVIDER HAS BEEN DIRECTED AND  TO  WHICH
THE  PROVIDER HAS BEEN GIVEN ACCESS SO THAT THE PROVIDER MAY IMMEDIATELY
PRINT AND RETAIN A HARD COPY.
  S 3. Paragraph (a) of subdivision 2 of  section  4914  of  the  public
health law, as amended by chapter 219 of the laws of 2011, is amended to
read as follows:

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01431-02-3

S. 5256                             2

  (a) The enrollee shall have four months to initiate an external appeal
after  the  enrollee  receives notice from the health care plan, or such
plan's utilization review agent if applicable, of a final adverse deter-
mination or denial or after both the plan and the enrollee have  jointly
agreed  to waive any internal appeal, or after the enrollee is deemed to
have exhausted or is not required to complete any internal appeal pursu-
ant to section 2719 of the  Public  Health  Service  Act,  42  U.S.C.  S
300gg-19.  Where  applicable,  the enrollee's health care provider shall
have [forty-five days] FOUR MONTHS to initiate an external appeal  after
the  enrollee  or  the  enrollee's  health care provider, as applicable,
receives notice from the health care plan, or  such  plan's  utilization
review  agent  if applicable, of a final adverse determination or denial
or after both the plan and the enrollee have jointly agreed to waive any
internal appeal. Such request shall be in writing in accordance with the
instructions and in such form prescribed by  subdivision  five  of  this
section.  The  enrollee,  and  the enrollee's health care provider where
applicable, shall have the opportunity to submit  additional  documenta-
tion with respect to such appeal to the external appeal agent within the
applicable time period above; provided however that when such documenta-
tion  represents a material change from the documentation upon which the
utilization review agent based its adverse determination or  upon  which
the health plan based its denial, the health plan shall have three busi-
ness  days  to  consider  such  documentation  and amend or confirm such
adverse determination.
  S 4. Subsection (g) of section 4903 of the insurance law, as added  by
chapter 586 of the laws of 1998, is amended to read as follows:
  (g)  Failure  by  the utilization review agent to make a determination
within the time periods prescribed in this section shall be deemed to be
an [adverse determination subject to appeal  pursuant  to  section  four
thousand nine hundred four of this title] APPROVAL.
  S  5.  The  opening paragraph of subsection (e) of section 4905 of the
insurance law is designated paragraph 1 and a new paragraph 2  is  added
to read as follows:
  (2)  WHENEVER A UTILIZATION REVIEW AGENT MAKES A VERBAL REPRESENTATION
REGARDING PREAUTHORIZATION OR APPROVAL,  THE  UTILIZATION  REVIEW  AGENT
SHALL IMMEDIATELY, BUT NO LATER THAN WITHIN ONE BUSINESS DAY, SUPPLY THE
PROVIDER WITH A WRITTEN CONFIRMATION OF THE APPROVAL BY EITHER:
  (I)  SENDING  A  COPY  OF  SUCH APPROVAL THROUGH ELECTRONIC MAIL TO AN
ADDRESS SPECIFIED BY THE PROVIDER;
  (II) SENDING A COPY OF SUCH APPROVAL THROUGH FACSIMILE TRANSMISSION TO
A NUMBER SPECIFIED BY THE PROVIDER; OR
  (III) POSTING A COPY OF SUCH APPROVAL ON A  SPECIFIC  WEBPAGE  OF  THE
INSURER'S  WEBSITE  TO WHICH THE PROVIDER HAS BEEN DIRECTED AND TO WHICH
THE PROVIDER HAS BEEN GIVEN ACCESS SO THAT THE PROVIDER MAY  IMMEDIATELY
PRINT AND RETAIN A HARD COPY.
  S  6.  Paragraph  1 of subsection (b) of section 4914 of the insurance
law, as amended by chapter 219 of the laws of 2011, is amended  to  read
as follows:
  (1)  The insured shall have four months to initiate an external appeal
after the insured receives notice from the health  care  plan,  or  such
plan's utilization review agent if applicable, of a final adverse deter-
mination  or denial, or after both the plan and the insured have jointly
agreed to waive any internal appeal, or after the insured is  deemed  to
have exhausted or is not required to complete any internal appeal pursu-
ant  to  section  2719  of  the  Public  Health Service Act, 42 U.S.C. S
300gg-19. Where applicable, the insured's  health  care  provider  shall

S. 5256                             3

have  [forty-five days] FOUR MONTHS to initiate an external appeal after
the insured or  the  insured's  health  care  provider,  as  applicable,
receives  notice  from  the health care plan, or such plan's utilization
review  agent  if applicable, of a final adverse determination or denial
or after both the plan and the insured have jointly agreed to waive  any
internal appeal. Such request shall be in writing in accordance with the
instructions  and  in  such  form  prescribed  by subsection (e) of this
section. The insured, and  the  insured's  health  care  provider  where
applicable,  shall  have the opportunity to submit additional documenta-
tion with respect to such appeal to the external appeal agent within the
applicable time period above; provided however that when such documenta-
tion represents a material change from the documentation upon which  the
utilization  review  agent based its adverse determination or upon which
the health plan based its denial, the health plan shall have three busi-
ness days to consider such  documentation  and  amend  or  confirm  such
adverse determination.
  S 7.  This act shall take effect July 1, 2014.

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