S T A T E   O F   N E W   Y O R K
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                                  5834

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                              June 17, 2013
                               ___________

Introduced  by  Sens.  HANNON, LARKIN -- read twice and ordered printed,
  and when printed to be committed to the Committee on Rules

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 2 of section 4903 of the public health law, as
added by chapter 705 of the laws of 1996, is amended to read as follows:
  2. A utilization review agent shall make a utilization review determi-
nation  involving  health  care services which require pre-authorization
and provide notice of a determination  to  the  enrollee  or  enrollee's
designee  and  the  enrollee's  health care provider by telephone and in
writing within three business days of receipt of the necessary  informa-
tion.    TO  THE  EXTENT  PRACTICABLE,  SUCH WRITTEN NOTIFICATION TO THE
ENROLLEE'S HEALTH CARE PROVIDER SHALL BE TRANSMITTED ELECTRONICALLY,  IN
A MANNER AND IN A FORM AGREED UPON BY THE PARTIES.
  S  2.  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:
  (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]  SIXTY  days 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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01431-06-3
              

S. 5834                             2

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 3.  Subsection (b) of section 4903 of the insurance law, as added by
chapter 705 of the laws of 1996, is amended to read as follows:
  (b) A utilization review agent shall make a utilization review  deter-
mination  involving health care services which require pre-authorization
and provide notice of a determination to the insured or insured's desig-
nee and the insured's health care provider by telephone and  in  writing
within  three business days of receipt of the necessary information.  TO
THE EXTENT PRACTICABLE, SUCH  WRITTEN  NOTIFICATION  TO  THE  ENROLLEE'S
HEALTH  CARE  PROVIDER  SHALL BE TRANSMITTED ELECTRONICALLY, IN A MANNER
AND IN A FORM AGREED UPON BY THE PARTIES.
  S 4. 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
have [forty-five] SIXTY days 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 5.  This act shall take effect July 1, 2014.