senate Bill S6281

Requires clinical peer reviewers to be licensed, registered or certified in this state and to be in the same specialty as the health care provider being reviewed

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Sponsor

Bill Status


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

  • 09 / Jan / 2014
    • REFERRED TO INSURANCE

Summary

Requires, for purposes of utilization review and external appeals, clinical peer reviewers to be licensed, registered or certified in this state and to be in the same specialty as the health care provider being reviewed.

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Bill Details

Versions:
S6281
Legislative Cycle:
2013-2014
Current Committee:
Senate Insurance
Law Section:
Insurance Law
Laws Affected:
Amd §4900, Ins L; amd §4900, Pub Health L

Sponsor Memo

BILL NUMBER:S6281 REVISED MEMO 01/10/14

TITLE OF BILL: An act to amend the insurance law and the public
health law, in relation to the definitions of "clinical peer reviewer"
for the purposes of utilization review and external appeal

PURPOSE:

This bill requires clinical peer reviewers to be licensed, registered
or certified in this state.

SUMMARY OF PROVISIONS:

Section 1 - Amends subsection (b) of section 4900 of the insurance
law, as amended by chapter 586 of the laws of 1998.

Section 2 Amends subdivision 2 of section 4900 of the public health
law, as amended by chapter 586 of the laws of 1998.

Section 3 - Effective date.

JUSTIFICATION:

Clinical peer reviewers of insurance claims are in a position to
second guess and deny insurance claims regarding a medical condition
or treatment ordered by a patient's physician or other authorized
health care provider. This bill would require all clinical peer
reviewers conducting utilization review and external appeals for New
York patients to be licensed, registered or certified in New York
State.

LEGISLATIVE HISTORY:

New bill

FISCAL IMPLICATIONS:

None

EFFECTIVE DATE:

This act shall take effect on the one hundred twentieth day after it
shall have become a law.

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

                                  6281

                            I N  S E N A T E

                             January 9, 2014
                               ___________

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

AN ACT to amend the insurance law and the public health law, in relation
  to the definitions of "clinical peer reviewer"  for  the  purposes  of
  utilization review and external appeal

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

  Section 1.  Subsection (b) of section 4900 of the  insurance  law,  as
amended  by  chapter  586  of  the  laws  of 1998, is amended to read as
follows:
  (b) "Clinical peer reviewer" means:
  (1) for purposes of title one of this article:
  (A) a physician who  possesses  a  current  and  valid  non-restricted
license  to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE
OF THE EDUCATION LAW; or
  (B) a health care professional other than a licensed physician who:
  (i) where applicable, possesses a  current  and  valid  non-restricted
license,  certificate  or  registration  [or,  where  no provision for a
license, certificate or registration  exists,  is  credentialed  by  the
national accrediting body appropriate to the profession] ISSUED PURSUANT
TO TITLE EIGHT OF THE EDUCATION LAW; and
  (ii)  is  in  the same profession and same or similar specialty as the
health care provider who typically  manages  the  medical  condition  or
disease  or  provides the health care service or treatment under review;
and
  (2) for purposes of title two of this article:
  (A) a physician who:
  (i) possesses a current and valid non-restricted license  to  practice
medicine  PURSUANT  TO  ARTICLE  ONE HUNDRED THIRTY-ONE OF THE EDUCATION
LAW;
  (ii) where applicable, is board certified or  board  eligible  in  the
same  or  similar  specialty  as  the health care provider who typically
manages the medical condition or disease or  provides  the  health  care
service or treatment under appeal;

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD13479-01-4

S. 6281                             2

  (iii) has been practicing in such area of specialty for a period of at
least five years; and
  (iv) is knowledgeable about the health care service or treatment under
appeal; or
  (B) a health care professional other than a licensed physician who:
  (i)  where  applicable,  possesses  a current and valid non-restricted
license, certificate or registration ISSUED PURSUANT TO TITLE  EIGHT  OF
THE EDUCATION LAW;
  (ii)  [where  applicable,  is credentialed by the national accrediting
body appropriate to the profession in the same profession  and  same  or
similar  specialty as the health care provider who typically manages the
medical condition or disease or provides  the  health  care  service  or
treatment under appeal;
  (iii)]  has  been practicing in such area of specialty for a period of
at least five years;
  [(iv)] (III) is knowledgeable about the health care service or  treat-
ment under appeal; and
  [(v)]  (IV)  where applicable to such health care professional's scope
of practice, is clinically supported by  a  physician  who  possesses  a
current  and  valid non-restricted license to practice medicine PURSUANT
TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW.
  (3) Nothing [herein] IN THIS ARTICLE shall be construed to change  any
statutorily-defined scope of practice.
  S  2.  Subdivision  2  of  section  4900  of the public health law, as
amended by chapter 586 of the laws  of  1998,  is  amended  to  read  as
follows:
  2. "Clinical peer reviewer" means:
  (a) for purposes of title one of this article:
  (i)  a  physician  who  possesses  a  current and valid non-restricted
license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED  THIRTY-ONE
OF THE EDUCATION LAW; or
  (ii) a health care professional other than a licensed physician who:
  (A)  where  applicable,  possesses  a current and valid non-restricted
license, certificate or registration  [or,  where  no  provision  for  a
license,  certificate  or  registration  exists,  is credentialed by the
national accrediting body appropriate to the profession] ISSUED PURSUANT
TO TITLE EIGHT OF THE EDUCATION LAW; and
  (B) is in the same profession and same or  similar  specialty  as  the
health  care  provider  who  typically  manages the medical condition or
disease or provides the health care service or treatment  under  review;
and
  (b) for purposes of title two of this article:
  (i) a physician who:
  (A)  possesses  a current and valid non-restricted license to practice
medicine PURSUANT TO ARTICLE ONE HUNDRED  THIRTY-ONE  OF  THE  EDUCATION
LAW;
  (B) where applicable, is board certified or board eligible in the same
or  similar  specialty as the health care provider who typically manages
the medical condition or disease or provides the health care service  or
treatment under appeal;
  (C)  has  been practicing in such area of specialty for a period of at
least five years; and
  (D) is knowledgeable about the health care service or treatment  under
appeal; or
  (ii) a health care professional other than a licensed physician who:

S. 6281                             3

  (A)  where  applicable,  possesses  a current and valid non-restricted
license, certificate or registration ISSUED PURSUANT TO TITLE  EIGHT  OF
THE EDUCATION LAW;
  (B)  [where  applicable,  is  credentialed by the national accrediting
body appropriate to the profession in the same profession  and  same  or
similar  specialty as the health care provider who typically manages the
medical condition or disease or provides  the  health  care  service  or
treatment under appeal;
  (C)]  has been practicing in such area of specialty for a period of at
least five years;
  [(D)] (C) is knowledgeable about the health care service or  treatment
under appeal; and
  [(E)] (D) where applicable to such health care professional's scope of
practice, is clinically supported by a physician who possesses a current
and  valid non-restricted license to practice medicine PURSUANT TO ARTI-
CLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW.
  (c) Nothing [herein] IN THIS ARTICLE shall be construed to change  any
statutorily-defined scope of practice.
  S 3. This act shall take effect on the one hundred twentieth day after
it shall have become a law.

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