Assembly Bill A3163

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

                                  3163

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                            January 23, 2009
                               ___________

Introduced by M. of A. BRADLEY, JACOBS, FIELDS, MILLMAN, DINOWITZ, BENE-
  DETTO, MARKEY, ENGLEBRIGHT, GALEF, BOYLAND, PHEFFER -- Multi-Sponsored
  by  --  M.  of A. CAHILL, COLTON, COOK, DelMONTE, GUNTHER, MAGNARELLI,
  MAYERSOHN, McENENY, REILLY, SCHIMEL, WRIGHT -- read once and  referred
  to the Committee on Insurance

AN ACT to amend the insurance law and the public health law, in relation
  to pre-authorization of care

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

  Section 1.  Subsection (e) of section 4905 of the  insurance  law,  as
added by chapter 705 of the laws of 1996, is amended to read as follows:
  (e)  If  a  health care service has been specifically preauthorized or
approved for an insured by a utilization  review  agent,  a  utilization
review agent shall not pursuant to retrospective review revise or modify
the  specific standards, criteria or procedures used for the utilization
review for procedures, treatment and services delivered to the  insured,
during the same course of treatment.
  (1)  WHENEVER A UTILIZATION REVIEW AGENT MAKES A VERBAL REPRESENTATION
REGARDING PREAUTHORIZATION OR APPROVAL,  THE  UTILIZATION  REVIEW  AGENT
SHALL  IMMEDIATELY THEREAFTER SUPPLY THE PROVIDER WITH A WRITTEN CONFIR-
MATION 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 WEBSITE ACCESSIBLE TO THE
PROVIDER SO THAT THE PROVIDER MAY IMMEDIATELY PRINT AND  RETAIN  A  HARD
COPY.
  (2) ABSENT A SHOWING OF MISREPRESENTATION ON BEHALF OF THE PROVIDER OR
THE  INSURED,  A COPY OF THE APPROVAL REQUIRED PURSUANT TO PARAGRAPH ONE
OF THIS SUBSECTION SHALL BE  PRIMA  FACIE  EVIDENCE  THAT  THE  SERVICES

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD03368-01-9
              

A. 3163                             2

PERFORMED  BY  THE  PROVIDER  WERE MEDICALLY NECESSARY COVERED SERVICES.
SUCH SERVICES SHALL NOT THEREAFTER  BE  DENIED  OR  LIMITED,  NOR  SHALL
REIMBURSEMENT  FOR  SUCH  SERVICES  BE  DENIED  OR  LIMITED. WHEN ACTUAL
SERVICES  RENDERED  DIFFER FROM THOSE SPECIFIC SERVICES PREAUTHORIZED OR
APPROVED DUE TO A RAPID CHANGE IN PATIENT NEEDS, SUCH SERVICES SHALL  BE
PRESUMPTIVELY APPROVED BUT MAY BE DENIED ON A RETROSPECTIVE REVIEW AFTER
PAYMENT IF SUCH SERVICES ARE DETERMINED NOT TO BE MEDICALLY NECESSARY.
  S  2. Subdivision 5 of section 4905 of the public health law, as added
by chapter 705 of the laws of 1996, is amended to read as follows:
  5. If a health care service has been  specifically  pre-authorized  or
approved  for  an  enrollee by a utilization review agent, a utilization
review agent shall not, pursuant  to  retrospective  review,  revise  or
modify  the  specific  standards,  criteria  or  procedures used for the
utilization review for procedures, treatment and services  delivered  to
the enrollee during the same course of treatment.
  (A)  WHENEVER A UTILIZATION REVIEW AGENT MAKES A VERBAL REPRESENTATION
REGARDING PREAUTHORIZATION OR APPROVAL,  THE  UTILIZATION  REVIEW  AGENT
SHALL  IMMEDIATELY THEREAFTER SUPPLY THE PROVIDER WITH A WRITTEN CONFIR-
MATION 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 WEBSITE ACCESSIBLE TO THE
PROVIDER SO THAT THE PROVIDER MAY IMMEDIATELY PRINT AND  RETAIN  A  HARD
COPY.
  (B) ABSENT A SHOWING OF MISREPRESENTATION ON BEHALF OF THE PROVIDER OR
THE  ENROLLEE, A COPY OF THE APPROVAL REQUIRED PURSUANT TO PARAGRAPH (A)
OF THIS SUBDIVISION SHALL BE PRIMA  FACIE  EVIDENCE  THAT  THE  SERVICES
PERFORMED  BY  THE  PROVIDER  WERE MEDICALLY NECESSARY COVERED SERVICES.
SUCH SERVICES SHALL NOT THEREAFTER  BE  DENIED  OR  LIMITED,  NOR  SHALL
REIMBURSEMENT  FOR  SUCH  SERVICES  BE  DENIED  OR  LIMITED. WHEN ACTUAL
SERVICES RENDERED DIFFER FROM THOSE SPECIFIC SERVICES  PREAUTHORIZED  OR
APPROVED  DUE TO A RAPID CHANGE IN PATIENT NEEDS, SUCH SERVICES SHALL BE
PRESUMPTIVELY APPROVED BUT MAY BE DENIED ON RETROSPECTIVE  REVIEW  AFTER
PAYMENT IF SUCH SERVICES ARE DETERMINED NOT TO BE MEDICALLY NECESSARY.
  S  3.  This  act  shall take effect on the sixtieth day after it shall
have become a law.