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

                                   501

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2015
                               ___________

Introduced by M. of A. CUSICK -- read once and referred to the Committee
  on Health

AN ACT to amend the public health law and the insurance law, in relation
  to  requiring  health  care  plans  and  insurers to provide expedited
  review of applications of health care professionals who are joining  a
  group practice and grant provisional credentials to such professionals

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

  Section 1.  Subdivision 1 of section 4406-d of the public health  law,
as  amended  by  chapter  237 of the laws of 2009, is amended to read as
follows:
  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 devel-
oping 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  ninety  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 in
spite of the health care plan's best efforts or because of a failure  of
a  third  party  to  provide  necessary documentation, or non-routine or
unusual circumstances  require  additional  time  for  review.  In  such
instances where additional time is necessary because of a lack of neces-
sary documentation, a health plan shall make every effort to obtain such
information  as  soon as possible. PROVIDED, HOWEVER, THAT IF THE APPLI-
CANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A  GROUP  PRACTICE  OF

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

                                                           LBD01643-01-5

A. 501                              2

HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACILITY OPERATING UNDER
ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR ARTICLE THIRTY-ONE OF THE MENTAL
HYGIENE  LAW  THAT  IS  A  PARTICIPATING PROVIDER IN THE HEALTH PLAN, AT
LEAST  ONE  OF  WHOM  PARTICIPATES IN THE IN-NETWORK PORTION OF A HEALTH
CARE PLAN'S NETWORK, A HEALTH CARE PLAN SHALL,  WITHIN  THIRTY  DAYS  OF
RECEIVING  SUCH  A  HEALTH  CARE  PROFESSIONAL'S COMPLETE APPLICATION TO
PARTICIPATE IN THE HEALTH CARE PLAN'S NETWORK, INCLUDING  SUBMISSION  OF
ALL  NECESSARY  DOCUMENTATION  FROM  THE  APPLICANT  AND  THIRD PARTIES,
COMPLETE REVIEW AND NOTIFY THE HEALTH CARE PROFESSIONAL AS TO WHETHER HE
OR SHE IS CREDENTIALED.
  (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 ninety days pursuant to
paragraph (a) of this subdivision, the health care professional shall be
deemed "provisionally credentialed" and may participate in  the  in-net-
work 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 HEALTH CARE
PROFESSIONAL DEEMED  provisionally  credentialed  [health  care  profes-
sional]  PURSUANT TO THIS PARAGRAPH shall begin on the day following the
ninetieth 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  noti-
fies  the health care plan in writing that, should the application ulti-
mately be denied, the health care professional or  the  group  practice:
(i)  shall  refund any payments made by the health care plan for in-net-
work 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)]  IT  SHALL  BE
UNDERSTOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT WILL
BE  APPROVED  BUT  HELD  BY  THE  HEALTH CARE PLAN UNTIL FINAL APPROVAL;
PROVIDED, HOWEVER, THAT IF REIMBURSEMENT IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER 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) IF THE APPLICANT IS A HEALTH CARE PROFESSIONAL WHO  IS  JOINING  A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY  OPERATING  UNDER  ARTICLE  TWENTY-EIGHT  OF THIS CHAPTER OR ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE HEALTH PLAN, AT LEAST ONE OF WHOM  PARTICIPATES  IN  THE  IN-NETWORK

A. 501                              3

PORTION OF A HEALTH CARE PLAN'S NETWORK, UPON HIS OR HER SUBMISSION OF A
COMPLETE  APPLICATION  TO PARTICIPATE IN THE HEALTH CARE PLAN'S NETWORK,
INCLUDING SUBMISSION OF ALL NECESSARY DOCUMENTATION FROM  THE  APPLICANT
AND  THIRD  PARTIES,  HE  OR  SHE SHALL BE DEEMED "PROVISIONALLY CREDEN-
TIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF THE HEALTH CARE
PLAN'S NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL
DEEMED PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN
ON THE DAY FOLLOWING NOTIFICATION BY  THE  HEALTH  CARE  PLAN  THAT  THE
COMPLETED  APPLICATION  WAS  RECEIVED  AND  SHALL  LAST  UNTIL THE FINAL
CREDENTIALING DETERMINATION IS MADE BY THE HEALTH CARE PLAN.
  (D) IF A HEALTH CARE PROFESSIONAL  IS  DEEMED  "PROVISIONALLY  CREDEN-
TIALED"  PURSUANT TO PARAGRAPH (B) OR (C) OF THIS SUBDIVISION, HE OR SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME AS THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL  BE  UNDER-
STOOD  THAT  PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT WILL BE
APPROVED BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL  APPROVAL;
PROVIDED,  HOWEVER,  THAT  IF REIMBURSEMENT IS DENIED, THE PROVISIONALLY
CREDENTIALED PROVIDER 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.
  (E)  IF  A  HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY A HEALTH
CARE PLAN PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR
TO EXPIRATION OR TERMINATION OF HIS OR HER CONTRACT WITH THE HEALTH CARE
PLAN, THE HEALTH CARE PROFESSIONAL OR THE  GROUP  PRACTICE  CHANGES  THE
ADDRESS  OF  OR  ADDS  AN ADDITIONAL LOCATION TO THE PRACTICE, HE OR SHE
SHALL NOT BE REQUIRED TO REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED
TO FILE NOTICE OF SUCH CHANGE OR ADDITION WITH THE HEALTH CARE PLAN.
  S 2. Subsection (a) of section 4803 of the insurance law,  as  amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (a)  (1)  An  insurer  which offers a managed care product shall, upon
request, make available and disclose to health care professionals  writ-
ten  application procedures and minimum qualification requirements which
a health care professional must meet in order to be  considered  by  the
insurer  for  participation  in  the  in-network benefits portion of the
insurer's network for  the  managed  care  product.  The  insurer  shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits  portion of the insurer's network for the managed care product.
An insurer shall complete  review  of  the  health  care  professional's
application  to  participate  in the in-network portion of the insurer's
network and, within ninety days  of  receiving  a  health  care  profes-
sional's  completed application to participate in the insurer's network,
will notify the health care professional as to: (A) whether he or she is
credentialed; or (B) whether additional time  is  necessary  to  make  a
determination  in  spite  of  the insurer's best efforts or because of a

A. 501                              4

failure of a third party to provide  necessary  documentation,  or  non-
routine or unusual circumstances require additional time for review.  In
such  instances  where additional time is necessary because of a lack of
necessary  documentation,  an  insurer shall make every effort to obtain
such information as soon as possible. PROVIDED,  HOWEVER,  THAT  IF  THE
APPLICANT  IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE
OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF  A  FACILITY  OPERATING
UNDER   ARTICLE  TWENTY-EIGHT  OF  THE  PUBLIC  HEALTH  LAW  OR  ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE HEALTH PLAN, AT LEAST ONE OF WHOM  PARTICIPATES  IN  THE  IN-NETWORK
PORTION OF AN INSURER'S NETWORK, AN INSURER SHALL, WITHIN THIRTY DAYS OF
RECEIVING  SUCH  A  HEALTH  CARE  PROFESSIONAL'S COMPLETE APPLICATION TO
PARTICIPATE IN AN INSURER'S NETWORK, INCLUDING SUBMISSION OF ALL  NECES-
SARY DOCUMENTATION FROM THE APPLICANT AND THIRD PARTIES, COMPLETE REVIEW
AND  NOTIFY  THE  HEALTH  CARE  PROFESSIONAL  AS TO WHETHER HE OR SHE IS
CREDENTIALED.
  (2) 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 an insurer's network, is
neither approved nor declined within ninety days pursuant  to  paragraph
one  of  this  subsection, such health care professional shall be deemed
"provisionally credentialed"  and  may  participate  in  the  in-network
portion  of  an  insurer's  network[;  provided,  however, that a provi-
sionally credentialed physician may not be designated  as  an  insured's
primary  care  physician until such time as the physician has been fully
credentialed]. The network participation for a HEALTH CARE  PROFESSIONAL
DEEMED provisionally credentialed [health care professional] PURSUANT TO
THIS  PARAGRAPH  shall  begin  on the day following the ninetieth day of
receipt of the completed application and  shall  last  until  the  final
credentialing  determination  is  made  by  the  insurer. [A health care
professional shall only be eligible for provisional credentialing if the
group practice of health care  professionals  notifies  the  insurer  in
writing  that,  should  the application ultimately be denied, the health
care professional or the group practice: (A) shall refund  any  payments
made  by  the  insurer  for  in-network  services provided by the provi-
sionally credentialed health care professional that exceed  any  out-of-
network  benefits payable under the insured's contract with the insurer;
and (B)] IT SHALL BE UNDERSTOOD THAT PROVISIONALLY CREDENTIALED  PROVID-
ERS'  REIMBURSEMENT  WILL  BE  APPROVED BUT HELD BY THE HEALTH CARE PLAN
UNTIL FINAL  APPROVAL;  PROVIDED,  HOWEVER,  THAT  IF  REIMBURSEMENT  IS
DENIED,   THE  PROVISIONALLY  CREDENTIALED  PROVIDER  shall  not  pursue
reimbursement from the insured, except to collect the copayment or coin-
surance that otherwise would have been payable had the insured  received
services from a health care professional participating in the in-network
portion  of  an  insurer's  network.  Interest and penalties pursuant to
section three thousand two hundred twenty-four-a of this  chapter  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  an  insurer  from
paying  a  claim  from  a  health care professional who is provisionally
credentialed upon submission of such claim. An insurer shall  not  deny,
after  appeal,  a claim for services provided by a provisionally creden-
tialed health care professional solely on the ground that the claim  was
not timely filed.

A. 501                              5

  (3)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY OPERATING UNDER ARTICLE TWENTY-EIGHT OF THE  PUBLIC  HEALTH  LAW  OR
ARTICLE  THIRTY-ONE  OF  THE  MENTAL HYGIENE LAW THAT IS A PARTICIPATING
PROVIDER  IN  THE  HEALTH PLAN, AT LEAST ONE OF WHOM PARTICIPATES IN THE
IN-NETWORK PORTION OF AN INSURER'S NETWORK, UPON HIS OR  HER  SUBMISSION
OF  A  COMPLETE  APPLICATION  TO  PARTICIPATE  IN THE INSURER'S NETWORK,
INCLUDING SUBMISSION OF ALL NECESSARY DOCUMENTATION FROM  THE  APPLICANT
AND  THIRD  PARTIES,  HE  OR  SHE SHALL BE DEEMED "PROVISIONALLY CREDEN-
TIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF  THE  INSURER'S
NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL DEEMED
PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN ON THE
DAY FOLLOWING NOTIFICATION BY THE INSURER THAT THE COMPLETED APPLICATION
WAS  RECEIVED AND SHALL LAST UNTIL THE FINAL CREDENTIALING DETERMINATION
IS MADE BY THE INSURER.
  (4) IF A HEALTH CARE PROFESSIONAL  IS  DEEMED  "PROVISIONALLY  CREDEN-
TIALED" PURSUANT TO PARAGRAPH TWO OR THREE OF THIS SUBSECTION, HE OR SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME  AS  THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL BE UNDER-
STOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT  WILL  BE
APPROVED  BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL APPROVAL;
PROVIDED, HOWEVER, THAT IF REIMBURSEMENT IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER  SHALL NOT PURSUE REIMBURSEMENT FROM THE INSURED,
EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
BEEN PAYABLE HAD THE  INSURED  RECEIVED  SERVICES  FROM  A  HEALTH  CARE
PROFESSIONAL  PARTICIPATING  IN  THE  IN-NETWORK PORTION OF AN INSURER'S
NETWORK. INTEREST AND PENALTIES PURSUANT TO SECTION THREE  THOUSAND  TWO
HUNDRED TWENTY-FOUR-A OF THIS CHAPTER 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  AN  INSURER  FROM PAYING A CLAIM FROM A
HEALTH  CARE  PROFESSIONAL  WHO  IS  PROVISIONALLY   CREDENTIALED   UPON
SUBMISSION  OF  SUCH  CLAIM.  AN INSURER 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.
  (5)  IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY AN INSURER
PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR TO  EXPI-
RATION  OR  TERMINATION  OF  HIS  OR  HER  CONTRACT WITH THE INSURER FOR
PARTICIPATION IN  THE  IN-NETWORK  BENEFITS  PORTION  OF  THE  INSURER'S
NETWORK  FOR A MANAGED CARE PRODUCT, THE HEALTH CARE PROFESSIONAL OR THE
GROUP PRACTICE CHANGES THE ADDRESS OF OR ADDS AN ADDITIONAL LOCATION  TO
THE  PRACTICE,  SUCH  HEALTH  CARE PROFESSIONAL SHALL NOT BE REQUIRED TO
REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED TO FILE NOTICE  OF  SUCH
CHANGE OR ADDITION WITH THE INSURER.
  S 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

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

                                 501--A
                                                        Cal. No. 285

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2015
                               ___________

Introduced by M. of A. CUSICK, ABINANTI -- read once and referred to the
  Committee  on  Health  -- reported from committee, advanced to a third
  reading, amended and ordered reprinted, retaining  its  place  on  the
  order of third reading

AN ACT to amend the public health law and the insurance law, in relation
  to  requiring  health  care  plans  and  insurers to provide expedited
  review of applications of health care professionals who are joining  a
  group practice and grant provisional credentials to such professionals

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

  Section 1. Paragraph (a) of subdivision 1 of  section  4406-d  of  the
public  health  law,  as  amended by chapter 237 of the laws of 2009, is
amended and three new paragraphs (c), (d) and (e) are added to  read  as
follows:
  (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 devel-
oping  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 ninety 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  in
spite  of the health care plan's best efforts or because of a failure of
a third party to provide  necessary  documentation,  or  non-routine  or
unusual  circumstances  require  additional  time  for  review.  In such
instances where additional time is necessary because of a lack of neces-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                      [ ] is old law to be omitted.
                                                           LBD01643-02-5

A. 501--A                           2

sary documentation, a health plan shall make every effort to obtain such
information as soon as possible. PROVIDED, HOWEVER, THAT IF  THE  APPLI-
CANT  IS  A  HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE OF
HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACILITY OPERATING UNDER
ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR ARTICLE THIRTY-ONE OF THE MENTAL
HYGIENE  LAW  THAT  IS  A  PARTICIPATING PROVIDER IN THE HEALTH PLAN, AT
LEAST ONE OF WHOM PARTICIPATES IN THE IN-NETWORK  PORTION  OF  A  HEALTH
CARE  PLAN'S  NETWORK,  A  HEALTH CARE PLAN SHALL, WITHIN THIRTY DAYS OF
RECEIVING SUCH A HEALTH  CARE  PROFESSIONAL'S  COMPLETE  APPLICATION  TO
PARTICIPATE  IN  THE HEALTH CARE PLAN'S NETWORK, INCLUDING SUBMISSION OF
ALL NECESSARY  DOCUMENTATION  FROM  THE  APPLICANT  AND  THIRD  PARTIES,
COMPLETE REVIEW AND NOTIFY THE HEALTH CARE PROFESSIONAL AS TO WHETHER HE
OR SHE IS CREDENTIALED.
  (C)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY OPERATING UNDER ARTICLE TWENTY-EIGHT  OF  THIS  CHAPTER  OR  ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE  HEALTH  PLAN,  AT  LEAST ONE OF WHOM PARTICIPATES IN THE IN-NETWORK
PORTION OF A HEALTH CARE PLAN'S NETWORK, UPON HIS OR HER SUBMISSION OF A
COMPLETE APPLICATION TO PARTICIPATE IN THE HEALTH CARE  PLAN'S  NETWORK,
INCLUDING  SUBMISSION  OF ALL NECESSARY DOCUMENTATION FROM THE APPLICANT
AND THIRD PARTIES, HE OR SHE  SHALL  BE  DEEMED  "PROVISIONALLY  CREDEN-
TIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF THE HEALTH CARE
PLAN'S NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL
DEEMED PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN
ON  THE  DAY  FOLLOWING  NOTIFICATION  BY  THE HEALTH CARE PLAN THAT THE
COMPLETED APPLICATION WAS  RECEIVED  AND  SHALL  LAST  UNTIL  THE  FINAL
CREDENTIALING DETERMINATION IS MADE BY THE HEALTH CARE PLAN.
  (D)  IF  A  HEALTH  CARE PROFESSIONAL IS DEEMED "PROVISIONALLY CREDEN-
TIALED" PURSUANT TO PARAGRAPH (B) OR (C) OF THIS SUBDIVISION, HE OR  SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME  AS  THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL BE UNDER-
STOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' SUCH APPROVAL  WILL  BE
APPROVED  BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL APPROVAL;
PROVIDED, HOWEVER, THAT IF SUCH APPROVAL IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER 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;
AND PROVIDED FURTHER THAT THE HEALTH  CARE  PLAN  SHALL  REIMBURSE  SUCH
HEALTH  CARE  PROFESSIONAL FOR ANY OUT OF NETWORK BENEFITS PAYABLE UNDER
THE ENROLLEE'S CONTRACT WITH THE HEALTH CARE PLAN.  INTEREST AND  PENAL-
TIES 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 PROVI-
SIONALLY 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  PROFES-
SIONAL SOLELY ON THE GROUND THAT THE CLAIM WAS NOT TIMELY FILED.
  (E)  IF  A  HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY A HEALTH
CARE PLAN PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR
TO EXPIRATION OR TERMINATION OF HIS OR HER CONTRACT WITH THE HEALTH CARE
PLAN, THE HEALTH CARE PROFESSIONAL OR THE  GROUP  PRACTICE  CHANGES  THE
ADDRESS  OF  OR  ADDS  AN ADDITIONAL LOCATION TO THE PRACTICE, HE OR SHE

A. 501--A                           3

SHALL NOT BE REQUIRED TO REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED
TO FILE NOTICE OF SUCH CHANGE OR ADDITION WITH THE HEALTH CARE PLAN.
  S  2.  Paragraph  1 of subsection (a) of section 4803 of the insurance
law, as amended by chapter 237 of the laws of 2009, is amended and three
new paragraphs 3, 4 and 5 are added to read as follows:
  (1) An insurer  which  offers  a  managed  care  product  shall,  upon
request,  make available and disclose to health care professionals writ-
ten application procedures and minimum qualification requirements  which
a  health  care  professional must meet in order to be considered by the
insurer for participation in the  in-network  benefits  portion  of  the
insurer's  network  for  the  managed  care  product.  The insurer shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits portion of the insurer's network for the managed care  product.
An  insurer  shall  complete  review  of  the health care professional's
application to participate in the in-network portion  of  the  insurer's
network  and,  within  ninety  days  of  receiving a health care profes-
sional's completed application to participate in the insurer's  network,
will notify the health care professional as to: (A) whether he or she is
credentialed;  or  (B)  whether  additional  time is necessary to make a
determination in spite of the insurer's best efforts  or  because  of  a
failure  of  a  third  party to provide necessary documentation, or non-
routine or unusual circumstances require additional time for review.  In
such instances where additional time is necessary because of a  lack  of
necessary  documentation,  an  insurer shall make every effort to obtain
such information as soon as possible. PROVIDED,  HOWEVER,  THAT  IF  THE
APPLICANT  IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE
OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF  A  FACILITY  OPERATING
UNDER   ARTICLE  TWENTY-EIGHT  OF  THE  PUBLIC  HEALTH  LAW  OR  ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE HEALTH PLAN, AT LEAST ONE OF WHOM  PARTICIPATES  IN  THE  IN-NETWORK
PORTION OF AN INSURER'S NETWORK, AN INSURER SHALL, WITHIN THIRTY DAYS OF
RECEIVING  SUCH  A  HEALTH  CARE  PROFESSIONAL'S COMPLETE APPLICATION TO
PARTICIPATE IN AN INSURER'S NETWORK, INCLUDING SUBMISSION OF ALL  NECES-
SARY DOCUMENTATION FROM THE APPLICANT AND THIRD PARTIES, COMPLETE REVIEW
AND  NOTIFY  THE  HEALTH  CARE  PROFESSIONAL  AS TO WHETHER HE OR SHE IS
CREDENTIALED.
  (3) IF THE APPLICANT IS A HEALTH CARE PROFESSIONAL WHO  IS  JOINING  A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY  OPERATING  UNDER  ARTICLE  TWENTY-EIGHT OF THE PUBLIC HEALTH LAW OR
ARTICLE THIRTY-ONE OF THE MENTAL HYGIENE LAW  THAT  IS  A  PARTICIPATING
PROVIDER  IN  THE  HEALTH PLAN, AT LEAST ONE OF WHOM PARTICIPATES IN THE
IN-NETWORK PORTION OF AN INSURER'S NETWORK, UPON HIS OR  HER  SUBMISSION
OF  A  COMPLETE  APPLICATION  TO  PARTICIPATE  IN THE INSURER'S NETWORK,
INCLUDING SUBMISSION OF ALL NECESSARY DOCUMENTATION FROM  THE  APPLICANT
AND  THIRD  PARTIES,  HE  OR  SHE SHALL BE DEEMED "PROVISIONALLY CREDEN-
TIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF  THE  INSURER'S
NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL DEEMED
PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN ON THE
DAY FOLLOWING NOTIFICATION BY THE INSURER THAT THE COMPLETED APPLICATION
WAS  RECEIVED AND SHALL LAST UNTIL THE FINAL CREDENTIALING DETERMINATION
IS MADE BY THE INSURER.
  (4) IF A HEALTH CARE PROFESSIONAL  IS  DEEMED  "PROVISIONALLY  CREDEN-
TIALED" PURSUANT TO PARAGRAPH TWO OR THREE OF THIS SUBSECTION, HE OR SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME  AS  THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL BE UNDER-

A. 501--A                           4

STOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT  WILL  BE
APPROVED  BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL APPROVAL;
PROVIDED, HOWEVER, THAT IF SUCH APPROVAL IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER  SHALL NOT PURSUE REIMBURSEMENT FROM THE INSURED,
EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
BEEN PAYABLE HAD THE  INSURED  RECEIVED  SERVICES  FROM  A  HEALTH  CARE
PROFESSIONAL  PARTICIPATING  IN  THE  IN-NETWORK PORTION OF AN INSURER'S
NETWORK; AND PROVIDED FURTHER THAT  THE  INSURER  SHALL  REIMBURSE  SUCH
HEALTH  CARE  PROFESSIONAL FOR ANY OUT OF NETWORK BENEFITS PAYABLE UNDER
THE INSURED'S CONTRACT WITH THE INSURER.  INTEREST AND PENALTIES  PURSU-
ANT  TO SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THIS CHAPTER
SHALL NOT BE ASSESSED BASED ON THE DENIAL OF A  CLAIM  SUBMITTED  DURING
THE  PERIOD  WHEN THE HEALTH CARE PROFESSIONAL WAS PROVISIONALLY CREDEN-
TIALED; PROVIDED, HOWEVER, THAT NOTHING HEREIN SHALL PREVENT AN  INSURER
FROM PAYING A CLAIM FROM A HEALTH CARE PROFESSIONAL WHO IS PROVISIONALLY
CREDENTIALED  UPON  SUBMISSION OF SUCH CLAIM. AN INSURER SHALL NOT DENY,
AFTER APPEAL, A CLAIM FOR SERVICES PROVIDED BY A  PROVISIONALLY  CREDEN-
TIALED  HEALTH CARE PROFESSIONAL SOLELY ON THE GROUND THAT THE CLAIM WAS
NOT TIMELY FILED.
  (5) IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY AN  INSURER
PURSUANT  TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR TO EXPI-
RATION OR TERMINATION OF HIS  OR  HER  CONTRACT  WITH  THE  INSURER  FOR
PARTICIPATION  IN  THE  IN-NETWORK  BENEFITS  PORTION  OF  THE INSURER'S
NETWORK FOR A MANAGED CARE PRODUCT, THE HEALTH CARE PROFESSIONAL OR  THE
GROUP  PRACTICE CHANGES THE ADDRESS OF OR ADDS AN ADDITIONAL LOCATION TO
THE PRACTICE, SUCH HEALTH CARE PROFESSIONAL SHALL  NOT  BE  REQUIRED  TO
REAPPLY  FOR  CERTIFICATION BUT SHALL BE REQUIRED TO FILE NOTICE OF SUCH
CHANGE OR ADDITION WITH THE INSURER.
  S 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

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

                                 501--B
                                                        Cal. No. 285

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2015
                               ___________

Introduced by M. of A. CUSICK, ABINANTI -- read once and referred to the
  Committee  on  Health  -- reported from committee, advanced to a third
  reading, amended and ordered reprinted, retaining  its  place  on  the
  order  of  third  reading  --  again amended on third reading, ordered
  reprinted, retaining its place on the order of third reading

AN ACT to amend the public health law and the insurance law, in relation
  to requiring health care  plans  and  insurers  to  provide  expedited
  review  of applications of health care professionals who are joining a
  group practice and  grant  provisional  credentials  to  such  profes-
  sionals; and to repeal certain provisions of the public health law and
  the insurance law relating thereto

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

  Section 1. Paragraph (a) of subdivision 1 of  section  4406-d  of  the
public  health  law,  as  amended by chapter 237 of the laws of 2009, is
amended, paragraph (b) is REPEALED and three new paragraphs (b), (c) and
(d) are added to read as follows:
  (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 devel-
oping 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  ninety  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 in
spite of the health care plan's best efforts or because of a failure  of

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                      [ ] is old law to be omitted.
                                                           LBD01643-06-5

A. 501--B                           2

a  third  party  to  provide  necessary documentation, or non-routine or
unusual circumstances  require  additional  time  for  review.  In  such
instances where additional time is necessary because of a lack of neces-
sary documentation, a health plan shall make every effort to obtain such
information  as  soon as possible. PROVIDED, HOWEVER, THAT IF THE APPLI-
CANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A  GROUP  PRACTICE  OF
HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACILITY OPERATING UNDER
ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR ARTICLE THIRTY-ONE OF THE MENTAL
HYGIENE  LAW  THAT  IS  A  PARTICIPATING PROVIDER IN THE HEALTH PLAN, AT
LEAST ONE OF WHOM PARTICIPATES IN THE IN-NETWORK  PORTION  OF  A  HEALTH
CARE  PLAN'S  NETWORK,  A  HEALTH CARE PLAN SHALL, WITHIN THIRTY DAYS OF
RECEIVING SUCH A HEALTH  CARE  PROFESSIONAL'S  COMPLETE  APPLICATION  TO
PARTICIPATE  IN  THE HEALTH CARE PLAN'S NETWORK, INCLUDING SUBMISSION OF
ALL NECESSARY  DOCUMENTATION  FROM  THE  APPLICANT  AND  THIRD  PARTIES,
COMPLETE REVIEW AND NOTIFY THE HEALTH CARE PROFESSIONAL AS TO WHETHER HE
OR SHE IS CREDENTIALED.
  (B)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY OPERATING UNDER ARTICLE TWENTY-EIGHT  OF  THIS  CHAPTER  OR  ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE  HEALTH  PLAN,  AT  LEAST ONE OF WHOM PARTICIPATES IN THE IN-NETWORK
PORTION OF A HEALTH CARE PLAN'S NETWORK, UPON HIS OR HER SUBMISSION OF A
COMPLETE APPLICATION TO PARTICIPATE IN THE HEALTH CARE  PLAN'S  NETWORK,
INCLUDING  SUBMISSION  OF ALL NECESSARY DOCUMENTATION FROM THE APPLICANT
AND THIRD PARTIES, HE OR SHE  SHALL  BE  DEEMED  "PROVISIONALLY  CREDEN-
TIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF THE HEALTH CARE
PLAN'S NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL
DEEMED PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN
ON  THE  DAY  FOLLOWING  NOTIFICATION  BY  THE HEALTH CARE PLAN THAT THE
COMPLETED APPLICATION WAS  RECEIVED  AND  SHALL  LAST  UNTIL  THE  FINAL
CREDENTIALING DETERMINATION IS MADE BY THE HEALTH CARE PLAN.
  (C)  IF  A  HEALTH  CARE PROFESSIONAL IS DEEMED "PROVISIONALLY CREDEN-
TIALED" PURSUANT TO PARAGRAPH (B) OF THIS SUBDIVISION, HE OR SHE MAY NOT
BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH TIME AS
THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL BE UNDERSTOOD  THAT
A  PROVISIONALLY  CREDENTIALED PROVIDER'S REIMBURSEMENT WILL BE APPROVED
BUT HELD BY THE HEALTH CARE PLAN UNTIL FINAL APPROVAL; PROVIDED,  HOWEV-
ER,  THAT  IF  SUCH  APPROVAL  IS DENIED, THE PROVISIONALLY CREDENTIALED
PROVIDER 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; AND  PROVIDED
FURTHER  THAT  THE  HEALTH  CARE  PLAN  SHALL REIMBURSE SUCH HEALTH CARE
PROFESSIONAL  FOR  ANY  OUT  OF  NETWORK  BENEFITS  PAYABLE  UNDER   THE
ENROLLEE'S  CONTRACT  WITH THE HEALTH CARE PLAN.  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 PROVI-
SIONALLY 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  PROFES-
SIONAL SOLELY ON THE GROUND THAT THE CLAIM WAS NOT TIMELY FILED.
  (D)  IF  A  HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY A HEALTH
CARE PLAN PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR

A. 501--B                           3

TO EXPIRATION OR TERMINATION OF HIS OR HER CONTRACT WITH THE HEALTH CARE
PLAN, THE HEALTH CARE PROFESSIONAL OR THE  GROUP  PRACTICE  CHANGES  THE
ADDRESS  OF  OR  ADDS  AN ADDITIONAL LOCATION TO THE PRACTICE, HE OR SHE
SHALL NOT BE REQUIRED TO REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED
TO FILE NOTICE OF SUCH CHANGE OR ADDITION WITH THE HEALTH CARE PLAN.
  S  2.  Paragraph  1 of subsection (a) of section 4803 of the insurance
law, as amended by chapter 237 of the laws of 2009,  is  amended,  para-
graph  2  is  REPEALED  and three new paragraphs 2, 3 and 4 are added to
read as follows:
  (1) An insurer  which  offers  a  managed  care  product  shall,  upon
request,  make available and disclose to health care professionals writ-
ten application procedures and minimum qualification requirements  which
a  health  care  professional must meet in order to be considered by the
insurer for participation in the  in-network  benefits  portion  of  the
insurer's  network  for  the  managed  care  product.  The insurer shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits portion of the insurer's network for the managed care  product.
An  insurer  shall  complete  review  of  the health care professional's
application to participate in the in-network portion  of  the  insurer's
network  and,  within  ninety  days  of  receiving a health care profes-
sional's completed application to participate in the insurer's  network,
will notify the health care professional as to: (A) whether he or she is
credentialed;  or  (B)  whether  additional  time is necessary to make a
determination in spite of the insurer's best efforts  or  because  of  a
failure  of  a  third  party to provide necessary documentation, or non-
routine or unusual circumstances require additional time for review.  In
such instances where additional time is necessary because of a  lack  of
necessary  documentation,  an  insurer shall make every effort to obtain
such information as soon as possible. PROVIDED,  HOWEVER,  THAT  IF  THE
APPLICANT  IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE
OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF  A  FACILITY  OPERATING
UNDER   ARTICLE  TWENTY-EIGHT  OF  THE  PUBLIC  HEALTH  LAW  OR  ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE HEALTH PLAN, AT LEAST ONE OF WHOM  PARTICIPATES  IN  THE  IN-NETWORK
PORTION OF AN INSURER'S NETWORK, AN INSURER SHALL, WITHIN THIRTY DAYS OF
RECEIVING  SUCH  A  HEALTH  CARE  PROFESSIONAL'S COMPLETE APPLICATION TO
PARTICIPATE IN AN INSURER'S NETWORK, INCLUDING SUBMISSION OF ALL  NECES-
SARY DOCUMENTATION FROM THE APPLICANT AND THIRD PARTIES, COMPLETE REVIEW
AND  NOTIFY  THE  HEALTH  CARE  PROFESSIONAL  AS TO WHETHER HE OR SHE IS
CREDENTIALED.
  (2) IF THE APPLICANT IS A HEALTH CARE PROFESSIONAL WHO  IS  JOINING  A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY  OPERATING  UNDER  ARTICLE  TWENTY-EIGHT OF THE PUBLIC HEALTH LAW OR
ARTICLE THIRTY-ONE OF THE MENTAL HYGIENE LAW  THAT  IS  A  PARTICIPATING
PROVIDER  IN  THE  HEALTH PLAN, AT LEAST ONE OF WHOM PARTICIPATES IN THE
IN-NETWORK PORTION OF AN INSURER'S NETWORK, UPON HIS OR  HER  SUBMISSION
OF  A  COMPLETE  APPLICATION  TO  PARTICIPATE  IN THE INSURER'S NETWORK,
INCLUDING SUBMISSION OF ALL NECESSARY DOCUMENTATION FROM  THE  APPLICANT
AND  THIRD  PARTIES,  HE  OR  SHE SHALL BE DEEMED "PROVISIONALLY CREDEN-
TIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF  THE  INSURER'S
NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL DEEMED
PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN ON THE
DAY FOLLOWING NOTIFICATION BY THE INSURER THAT THE COMPLETED APPLICATION
WAS  RECEIVED AND SHALL LAST UNTIL THE FINAL CREDENTIALING DETERMINATION
IS MADE BY THE INSURER.

A. 501--B                           4

  (3) IF A HEALTH CARE PROFESSIONAL  IS  DEEMED  "PROVISIONALLY  CREDEN-
TIALED"  PURSUANT TO PARAGRAPH TWO OF THIS SUBSECTION, HE OR SHE MAY NOT
BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH TIME AS
THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL BE UNDERSTOOD  THAT
A  PROVISIONALLY  CREDENTIALED PROVIDER'S REIMBURSEMENT WILL BE APPROVED
BUT HELD BY THE HEALTH CARE PLAN UNTIL FINAL APPROVAL; PROVIDED,  HOWEV-
ER,  THAT  IF  SUCH  APPROVAL  IS DENIED, THE PROVISIONALLY CREDENTIALED
PROVIDER SHALL NOT PURSUE REIMBURSEMENT  FROM  THE  INSURED,  EXCEPT  TO
COLLECT  THE  COPAYMENT  OR  COINSURANCE  THAT OTHERWISE WOULD HAVE BEEN
PAYABLE HAD THE INSURED RECEIVED SERVICES FROM  A  HEALTH  CARE  PROFES-
SIONAL  PARTICIPATING IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK;
AND PROVIDED FURTHER THAT THE INSURER SHALL REIMBURSE SUCH  HEALTH  CARE
PROFESSIONAL FOR ANY OUT OF NETWORK BENEFITS PAYABLE UNDER THE INSURED'S
CONTRACT  WITH  THE INSURER.  INTEREST AND PENALTIES PURSUANT TO SECTION
THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THIS CHAPTER  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  AN  INSURER  FROM  PAYING  A
CLAIM  FROM A HEALTH CARE PROFESSIONAL WHO IS PROVISIONALLY CREDENTIALED
UPON SUBMISSION OF SUCH CLAIM. AN INSURER 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.
  (4)  IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY AN INSURER
PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR TO  EXPI-
RATION  OR  TERMINATION  OF  HIS  OR  HER  CONTRACT WITH THE INSURER FOR
PARTICIPATION IN  THE  IN-NETWORK  BENEFITS  PORTION  OF  THE  INSURER'S
NETWORK  FOR A MANAGED CARE PRODUCT, THE HEALTH CARE PROFESSIONAL OR THE
GROUP PRACTICE CHANGES THE ADDRESS OF OR ADDS AN ADDITIONAL LOCATION  TO
THE  PRACTICE,  SUCH  HEALTH  CARE PROFESSIONAL SHALL NOT BE REQUIRED TO
REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED TO FILE NOTICE  OF  SUCH
CHANGE OR ADDITION WITH THE INSURER.
  S 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

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

                                 501--C
                                                        Cal. No. 355

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2015
                               ___________

Introduced by M. of A. CUSICK, ABINANTI -- read once and referred to the
  Committee  on  Health  -- reported from committee, advanced to a third
  reading, amended and ordered reprinted, retaining  its  place  on  the
  order  of  third  reading  --  again amended on third reading, ordered
  reprinted, retaining its place on the order of third reading -- recom-
  mitted to the Committee on Health in accordance with Assembly Rule  3,
  sec.  2  --  reported  from  committee,  advanced  to a third reading,
  amended and ordered reprinted, retaining its place  on  the  order  of
  third reading

AN ACT to amend the public health law and the insurance law, in relation
  to  requiring  health  care  plans  and  insurers to provide expedited
  review of applications of health care professionals who are joining  a
  group  practice  and  grant  provisional  credentials  to such profes-
  sionals; and to repeal certain provisions of the public health law and
  the insurance law relating thereto

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

  Section  1.  Paragraph  (a)  of subdivision 1 of section 4406-d of the
public health law, as amended by chapter 237 of the  laws  of  2009,  is
amended, paragraph (b) is REPEALED and three new paragraphs (b), (c) and
(d) are added to read as follows:
  (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 devel-
oping  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 ninety days of receiving a health care  professional's  completed

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                      [ ] is old law to be omitted.
                                                           LBD01643-08-6

A. 501--C                           2

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  in
spite  of the health care plan's best efforts or because of a failure of
a third party to provide  necessary  documentation,  or  non-routine  or
unusual  circumstances  require  additional  time  for  review.  In such
instances where additional time is necessary because of a lack of neces-
sary documentation, a health plan shall make every effort to obtain such
information as soon as possible. PROVIDED, HOWEVER, THAT IF  THE  APPLI-
CANT  IS  A  HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE OF
HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACILITY OPERATING UNDER
ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR ARTICLE THIRTY-ONE OF THE MENTAL
HYGIENE LAW THAT IS A PARTICIPATING PROVIDER  IN  THE  HEALTH  PLAN,  AT
LEAST  ONE  OF  WHOM  PARTICIPATES IN THE IN-NETWORK PORTION OF A HEALTH
CARE PLAN'S NETWORK, A HEALTH CARE PLAN SHALL,  WITHIN  THIRTY  DAYS  OF
RECEIVING  SUCH  A  HEALTH  CARE  PROFESSIONAL'S COMPLETE APPLICATION TO
PARTICIPATE IN THE HEALTH CARE PLAN'S NETWORK, INCLUDING  SUBMISSION  OF
ALL  NECESSARY  DOCUMENTATION  FROM  THE  APPLICANT  AND  THIRD PARTIES,
COMPLETE REVIEW AND NOTIFY THE HEALTH CARE PROFESSIONAL AS TO WHETHER HE
OR SHE IS CREDENTIALED.
  (B) IF THE APPLICANT IS A HEALTH CARE PROFESSIONAL WHO  IS  JOINING  A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY  OPERATING  UNDER  ARTICLE  TWENTY-EIGHT  OF THIS CHAPTER OR ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE HEALTH PLAN, AT LEAST ONE OF WHOM  PARTICIPATES  IN  THE  IN-NETWORK
PORTION OF A HEALTH CARE PLAN'S NETWORK, UPON HIS OR HER SUBMISSION OF A
COMPLETE  APPLICATION  TO PARTICIPATE IN THE HEALTH CARE PLAN'S NETWORK,
INCLUDING SUBMISSION OF ALL NECESSARY DOCUMENTATION FROM  THE  APPLICANT
AND  THIRD  PARTIES,  HE  OR  SHE SHALL BE DEEMED "PROVISIONALLY CREDEN-
TIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF THE HEALTH CARE
PLAN'S NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL
DEEMED PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN
ON THE DAY FOLLOWING NOTIFICATION BY  THE  HEALTH  CARE  PLAN  THAT  THE
COMPLETED  APPLICATION  WAS  RECEIVED  AND  SHALL  LAST  UNTIL THE FINAL
CREDENTIALING DETERMINATION IS MADE BY THE HEALTH CARE PLAN.
  (C) IF A HEALTH CARE PROFESSIONAL  IS  DEEMED  "PROVISIONALLY  CREDEN-
TIALED" PURSUANT TO PARAGRAPH (B) OF THIS SUBDIVISION, HE OR SHE MAY NOT
BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH TIME AS
THE  PHYSICIAN  HAS  BEEN  FULLY  CREDENTIALED.  IF  SUCH APPLICATION TO
PARTICIPATE IN THE  NETWORK  ULTIMATELY  IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER SHALL NOT PURSUE REIMBURSEMENT FROM THE ENROLLEE,
EXCEPT TO COLLECT THE COPAYMENT, COINSURANCE OR DEDUCTIBLE  THAT  OTHER-
WISE  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; AND PROVIDED FURTHER THAT THE HEALTH CARE
PLAN SHALL REIMBURSE SUCH  HEALTH  CARE  PROFESSIONAL  FOR  ANY  OUT  OF
NETWORK  BENEFITS  PAYABLE UNDER THE ENROLLEE'S CONTRACT WITH THE HEALTH
CARE PLAN.  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

A. 501--C                           3

CREDENTIALED  HEALTH  CARE  PROFESSIONAL  SOLELY  ON THE GROUND THAT THE
CLAIM WAS NOT TIMELY FILED.
  (D)  IF  A  HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY A HEALTH
CARE PLAN PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR
TO EXPIRATION OR TERMINATION OF HIS OR HER CONTRACT WITH THE HEALTH CARE
PLAN, THE HEALTH CARE PROFESSIONAL OR THE  GROUP  PRACTICE  CHANGES  THE
ADDRESS  OF  OR  ADDS  AN ADDITIONAL LOCATION TO THE PRACTICE, HE OR SHE
SHALL NOT BE REQUIRED TO REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED
TO FILE NOTICE OF SUCH CHANGE OR ADDITION WITH THE HEALTH CARE PLAN.
  S 2. Paragraph 1 of subsection (a) of section 4803  of  the  insurance
law,  as  amended  by chapter 237 of the laws of 2009, is amended, para-
graph 2 is REPEALED and three new paragraphs 2, 3 and  4  are  added  to
read as follows:
  (1)  An  insurer  which  offers  a  managed  care  product shall, upon
request, make available and disclose to health care professionals  writ-
ten  application procedures and minimum qualification requirements which
a health care professional must meet in order to be  considered  by  the
insurer  for  participation  in  the  in-network benefits portion of the
insurer's network for  the  managed  care  product.  The  insurer  shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits  portion of the insurer's network for the managed care product.
An insurer shall complete  review  of  the  health  care  professional's
application  to  participate  in the in-network portion of the insurer's
network and, within ninety days  of  receiving  a  health  care  profes-
sional's  completed application to participate in the insurer's network,
will notify the health care professional as to: (A) whether he or she is
credentialed; or (B) whether additional time  is  necessary  to  make  a
determination  in  spite  of  the insurer's best efforts or because of a
failure of a third party to provide  necessary  documentation,  or  non-
routine or unusual circumstances require additional time for review.  In
such  instances  where additional time is necessary because of a lack of
necessary documentation, an insurer shall make every  effort  to  obtain
such  information  as  soon  as possible. PROVIDED, HOWEVER, THAT IF THE
APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP  PRACTICE
OF  HEALTH  CARE  PROFESSIONALS, OR NEW EMPLOYEE OF A FACILITY OPERATING
UNDER  ARTICLE  TWENTY-EIGHT  OF  THE  PUBLIC  HEALTH  LAW  OR   ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE  HEALTH  PLAN,  AT  LEAST ONE OF WHOM PARTICIPATES IN THE IN-NETWORK
PORTION OF AN INSURER'S NETWORK, AN INSURER SHALL, WITHIN THIRTY DAYS OF
RECEIVING SUCH A HEALTH  CARE  PROFESSIONAL'S  COMPLETE  APPLICATION  TO
PARTICIPATE  IN AN INSURER'S NETWORK, INCLUDING SUBMISSION OF ALL NECES-
SARY DOCUMENTATION FROM THE APPLICANT AND THIRD PARTIES, COMPLETE REVIEW
AND NOTIFY THE HEALTH CARE PROFESSIONAL AS  TO  WHETHER  HE  OR  SHE  IS
CREDENTIALED.
  (2)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY OPERATING UNDER ARTICLE TWENTY-EIGHT OF THE  PUBLIC  HEALTH  LAW  OR
ARTICLE  THIRTY-ONE  OF  THE  MENTAL HYGIENE LAW THAT IS A PARTICIPATING
PROVIDER IN THE HEALTH PLAN, AT LEAST ONE OF WHOM  PARTICIPATES  IN  THE
IN-NETWORK  PORTION  OF AN INSURER'S NETWORK, UPON HIS OR HER SUBMISSION
OF A COMPLETE APPLICATION  TO  PARTICIPATE  IN  THE  INSURER'S  NETWORK,
INCLUDING  SUBMISSION  OF ALL NECESSARY DOCUMENTATION FROM THE APPLICANT
AND THIRD PARTIES, HE OR SHE  SHALL  BE  DEEMED  "PROVISIONALLY  CREDEN-
TIALED"  AND  MAY PARTICIPATE IN THE IN-NETWORK PORTION OF THE INSURER'S
NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL DEEMED

A. 501--C                           4

PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN ON THE
DAY FOLLOWING NOTIFICATION BY THE INSURER THAT THE COMPLETED APPLICATION
WAS RECEIVED AND SHALL LAST UNTIL THE FINAL CREDENTIALING  DETERMINATION
IS MADE BY THE INSURER.
  (3)  IF  A  HEALTH  CARE PROFESSIONAL IS DEEMED "PROVISIONALLY CREDEN-
TIALED" PURSUANT TO PARAGRAPH TWO OF THIS SUBSECTION, HE OR SHE MAY  NOT
BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH TIME AS
THE  PHYSICIAN  HAS  BEEN  FULLY  CREDENTIALED.  IF  SUCH APPLICATION TO
PARTICIPATE IN THE  NETWORK  ULTIMATELY  IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER  SHALL NOT PURSUE REIMBURSEMENT FROM THE INSURED,
EXCEPT TO COLLECT THE COPAYMENT, COINSURANCE OR DEDUCTIBLE  THAT  OTHER-
WISE  WOULD  HAVE  BEEN PAYABLE HAD THE INSURED RECEIVED SERVICES FROM A
HEALTH CARE PROFESSIONAL PARTICIPATING IN THE IN-NETWORK PORTION  OF  AN
INSURER'S NETWORK; AND PROVIDED FURTHER THAT THE INSURER SHALL REIMBURSE
SUCH  HEALTH  CARE  PROFESSIONAL FOR ANY OUT OF NETWORK BENEFITS PAYABLE
UNDER THE INSURED'S CONTRACT WITH THE INSURER.   INTEREST AND  PENALTIES
PURSUANT  TO  SECTION  THREE  THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THIS
CHAPTER 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  AN
INSURER  FROM  PAYING  A  CLAIM  FROM  A HEALTH CARE PROFESSIONAL WHO IS
PROVISIONALLY CREDENTIALED UPON SUBMISSION OF  SUCH  CLAIM.  AN  INSURER
SHALL  NOT DENY, AFTER APPEAL, A CLAIM FOR SERVICES PROVIDED BY A PROVI-
SIONALLY CREDENTIALED HEALTH CARE PROFESSIONAL SOLELY ON THE GROUND THAT
THE CLAIM WAS NOT TIMELY FILED.
  (4) IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY AN  INSURER
PURSUANT  TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR TO EXPI-
RATION OR TERMINATION OF HIS  OR  HER  CONTRACT  WITH  THE  INSURER  FOR
PARTICIPATION  IN  THE  IN-NETWORK  BENEFITS  PORTION  OF  THE INSURER'S
NETWORK FOR A MANAGED CARE PRODUCT, THE HEALTH CARE PROFESSIONAL OR  THE
GROUP  PRACTICE CHANGES THE ADDRESS OF OR ADDS AN ADDITIONAL LOCATION TO
THE PRACTICE, SUCH HEALTH CARE PROFESSIONAL SHALL  NOT  BE  REQUIRED  TO
REAPPLY  FOR  CERTIFICATION BUT SHALL BE REQUIRED TO FILE NOTICE OF SUCH
CHANGE OR ADDITION WITH THE INSURER.
  S 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

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

                                 501--D
                                                        Cal. No. 355

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2015
                               ___________

Introduced by M. of A. CUSICK, ABINANTI -- read once and referred to the
  Committee  on  Health  -- reported from committee, advanced to a third
  reading, amended and ordered reprinted, retaining  its  place  on  the
  order  of  third  reading  --  again amended on third reading, ordered
  reprinted, retaining its place on the order of third reading -- recom-
  mitted to the Committee on Health in accordance with Assembly Rule  3,
  sec.  2  --  reported  from  committee,  advanced  to a third reading,
  amended and ordered reprinted, retaining its place  on  the  order  of
  third  reading  --  again amended on third reading, ordered reprinted,
  retaining its place on the order of third reading

AN ACT to amend the public health law and the insurance law, in relation
  to requiring health care  plans  and  insurers  to  provide  expedited
  review  of applications of health care professionals who are joining a
  group practice and grant provisional credentials to such professionals

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

  Section  1.  Subdivision 1 of section 4406-d of the public health law,
as amended by chapter 237 of the laws of 2009, is  amended  to  read  as
follows:
  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 devel-
oping  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 [ninety] 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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                      [ ] is old law to be omitted.
                                                           LBD01643-10-6

A. 501--D                           2

credentialed;  or  (ii)  whether  additional time is necessary to make a
determination [in spite of the  health  care  plan's  best  efforts  or]
because  of  a  failure of a third party to provide necessary documenta-
tion[,  or  non-routine or unusual circumstances require additional time
for review]. 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 [ninety] 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 creden-
tialed. The  network  participation  for  a  provisionally  credentialed
health  care  professional shall begin on the day following the [nineti-
eth] 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  noti-
fies  the health care plan in writing that, should the application ulti-
mately be denied, the health care professional or  the  group  practice:
(i)  shall  refund any payments made by the health care plan for in-net-
work 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  creden-
tialed;  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.
  S  2.  Subsection (a) of section 4803 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (a) (1) An insurer which offers a managed  care  product  shall,  upon
request,  make available and disclose to health care professionals writ-
ten application procedures and minimum qualification requirements  which
a  health  care  professional must meet in order to be considered by the
insurer for participation in the  in-network  benefits  portion  of  the
insurer's  network  for  the  managed  care  product.  The insurer shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network

A. 501--D                           3

benefits portion of the insurer's network for the managed care  product.
An  insurer  shall  complete  review  of  the health care professional's
application to participate in the in-network portion  of  the  insurer's
network  and,  within  [ninety]  SIXTY  days  of receiving a health care
professional's completed application to  participate  in  the  insurer's
network,  will notify the health care professional as to: (A) whether he
or she is credentialed; or (B) whether additional time is  necessary  to
make a determination [in spite of the insurer's best efforts or] because
of  a  failure  of a third party to provide necessary documentation[, or
non-routine  or  unusual  circumstances  require  additional  time   for
review].    In such instances where additional time is necessary because
of a lack of necessary documentation, an insurer 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 DOCUMEN-
TATION.
  (2)  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 an insurer's network,  is
neither  approved  nor declined within [ninety] SIXTY days OF SUBMISSION
OF A COMPLETED APPLICATION pursuant to paragraph one of this subsection,
such health care professional shall  be  deemed  "provisionally  creden-
tialed"  and  may  participate in the in-network portion of an insurer's
network; provided, however, that a provisionally credentialed  physician
may  not be designated as an insured's primary care physician until such
time as the physician has been fully credentialed. The  network  partic-
ipation  for a provisionally credentialed health care professional shall
begin on the day following the [ninetieth] SIXTIETH day  of  receipt  of
the  completed  application and shall last until the final credentialing
determination is made by the insurer. A health care  professional  shall
only  be eligible for provisional credentialing if the group practice of
health care professionals notifies the insurer in writing  that,  should
the  application  ultimately  be denied, the health care professional or
the group practice: (A) shall refund any payments made  by  the  insurer
for  in-network  services  provided  by  the  provisionally credentialed
health care professional that exceed any out-of-network benefits payable
under the insured's contract with the insurer; and (B) shall not  pursue
reimbursement from the insured, except to collect the copayment or coin-
surance  that otherwise would have been payable had the insured received
services from a health care professional participating in the in-network
portion of an insurer's network.  Interest  and  penalties  pursuant  to
section  three  thousand two hundred twenty-four-a of this chapter 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 an insurer from
paying a claim from a health  care  professional  who  is  provisionally
credentialed  upon  submission of such claim. An insurer shall not deny,
after appeal, a claim for services provided by a  provisionally  creden-
tialed  health care professional solely on the ground that the claim was
not timely filed.
  S 3. This act shall take effect on April 1, 2017.