LBD00403-02-9
A. 793 2
SEVEN-J OF THIS CHAPTER, WITH THE EXCEPTION OF GOVERNMENTAL AGENCIES,
BUT SHALL INCLUDE THIRD PARTY PAYERS THAT ENROLL PERSONS ELIGIBLE FOR
MEDICAL ASSISTANCE PURSUANT TO SECTION THREE HUNDRED SIXTY-FOUR-J OF THE
SOCIAL SERVICES LAW, OR A REPRESENTATIVE DESIGNATED BY SUCH ENTITY.
(C) ADMINISTRATION OF ALTERNATIVE DISPUTE RESOLUTION SYSTEM. THE
COMMISSIONER SHALL SELECT AND APPROVE STATEWIDE OR REGIONAL ALTERNATIVE
DISPUTE RESOLUTION AGENTS TO CONDUCT AND DETERMINE ALTERNATIVE DISPUTE
RESOLUTION REVIEWS. THE COMMISSIONER SHALL ESTABLISH CRITERIA FOR THE
SELECTION OF SUCH AGENTS, INCLUDING BUT NOT LIMITED TO THE FOLLOWING:
I. EMPLOYMENT OR CONTROL THROUGH OTHER ARRANGEMENTS OF A SUFFICIENT
NUMBER OF PERSONNEL QUALIFIED TO REVIEW DISPUTES, INCLUDING SUFFICIENT
PHYSICIAN AND OTHER CLINICAL SPECIALISTS WHERE APPROPRIATE;
II. DEMONSTRATION OF AN ABILITY TO REVIEW AND RENDER DECISIONS REGARD-
ING DISPUTES IN A TIMELY MANNER;
III. ABILITY TO MAKE AVAILABLE FOR INSPECTION BY THE COMMISSIONER AND
SUPERINTENDENT OF INSURANCE RECORDS AND INFORMATION RELATED TO ITS
REVIEW ACTIVITIES;
IV. LACK OF CONFLICT OF INTEREST BASED ON PAYER, PROVIDER, OR PROFES-
SIONAL AFFILIATION, INCLUDING PROCEDURES TO ENSURE THAT CASES SUBMITTED
FOR REVIEW THAT HAVE BEEN PREVIOUSLY REVIEWED BY THE AGENT IN A SEPARATE
CAPACITY ARE IDENTIFIED FOR REASSIGNMENT TO OTHER AGENTS;
V. FAMILIARITY WITH BILLING, CODING, AND CLAIMS PAYMENT PRACTICES OF
HEALTH CARE PAYERS AND PROVIDERS IN NEW YORK STATE;
VI. FAMILIARITY WITH THE NATURE OF CONTRACTUAL RELATIONSHIPS BETWEEN
PAYERS AND PROVIDERS;
VII. FAMILIARITY WITH RELEVANT PROVISIONS OF THIS ARTICLE AND THE
INSURANCE LAW AND RELATED RULES AND REGULATIONS CONCERNING THE DELIVERY
AND REVIEW OF, AND BILLING AND PAYMENT FOR, HEALTH CARE SERVICES;
VIII. ABILITY TO ENSURE CONFIDENTIALITY OF PATIENT INFORMATION;
IX. ABILITY TO PROMOTE UNIFORMITY IN THE INTERPRETATION OF APPLICABLE
LAWS, REGULATIONS, AND CONTRACTUAL PROVISIONS AS DEFINED BY THE COMMIS-
SIONER AND SUPERINTENDENT OF INSURANCE; AND
X. ABILITY TO ESTABLISH POLICIES AND PROCEDURES AND TO CARRY OUT THE
PROVISIONS OF THIS SECTION.
(D) MINIMUM AMOUNT IN DISPUTE. I. NO DISPUTE SHALL BE ACCEPTED FOR
REVIEW BY THE ALTERNATIVE DISPUTE RESOLUTION SYSTEM UNLESS THE CLAIMED
VALUE OF THE DISPUTED ITEM OR SERVICE IS FIVE HUNDRED DOLLARS OR MORE,
PROVIDED, HOWEVER, THAT A DISPUTED ITEM OR SERVICE MAY INCLUDE MULTIPLE
ITEMS WHOSE AGGREGATE VALUE MEETS THE MINIMUM REQUIREMENT WHEN THE
DISPUTE IS ALLEGED TO ARISE FROM THE SAME PATTERN OR PRACTICE APPLIED TO
SUCH MULTIPLE ITEMS.
II. EXCEPT FOR DISPUTES WHICH MAY BE CONSIDERED AND RESOLVED UNDER
TITLE TWO OF ARTICLE FORTY-NINE OF THIS CHAPTER OR TITLE TWO OF ARTICLE
FORTY-NINE OF THE INSURANCE LAW AS IMPLEMENTED THROUGH THE SUPERINTEN-
DENT OF INSURANCE OR THE COMMISSIONER'S ADMINISTRATIVE PRACTICES OR
THROUGH REGULATION, THE DISPUTE RESOLUTION SYSTEM ESTABLISHED BY THIS
SUBDIVISION SHALL REVIEW DISAGREEMENTS RELATED TO THE PROVISIONS OF
SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THE INSURANCE LAW;
THE PROVISIONS OF STATE OR FEDERAL LAW OR REGULATION; THE PROCESS AND
PROCEDURES UTILIZED BY THIRD PARTY PAYERS FOR THE SUBMISSION, REVIEW,
AND APPEAL OF CLAIMS; CONTRACTUAL PROVISIONS RELATED TO PAYMENT AND
MEDICAL REVIEW; AND OTHER DISPUTES RELATED TO PAYMENT AMOUNTS AND BILL-
ING AND CLAIMS ADJUDICATION PRACTICES. DISPUTES SUBJECT TO REVIEW SHALL
INCLUDE, BUT NOT BE LIMITED TO:
A. DISPUTES REGARDING PAYMENT RESULTING FROM THE REVIEW OF A HEALTH
CARE PROCEDURE, SERVICE, OR SERVICES CONDUCTED PURSUANT TO ARTICLE
A. 793 3
FORTY-NINE OF THIS CHAPTER OR ARTICLE FORTY-NINE OF THE INSURANCE LAW,
REGARDLESS OF WHEN THE REVIEW WAS BEGUN OR COMPLETED; PROVIDED, HOWEVER,
THAT IF THE PERSON RECEIVING THE HEALTH CARE PROCEDURE OR SERVICE THAT
GAVE RISE TO THE PAYMENT DISPUTE IS FINANCIALLY LIABLE FOR PART OR ALL
OF THE DISPUTED PAYMENT, SUCH PERSON HAS GIVEN HIS OR HER CONSENT IN
WRITING TO PERMIT THE PROVIDER OR PAYER TO PURSUE THE DISPUTE, WHICH
CONSENT MAY BE PROVIDED IN ADVANCE OF THE PROVISION OF THE PROCEDURE OR
SERVICE AND WHICH SHALL BE INCLUDED IN THE MATERIALS SUBMITTED TO THE
REVIEW AGENT IN SUPPORT OF THE REVIEW;
B. DISPUTES REGARDING PAYMENT RELATED TO THE PRIOR AUTHORIZATION OF A
SERVICE;
C. DISPUTES REGARDING PROVISIONS OF STATE OR FEDERAL LAW OR REGULATION
RELATED TO THE APPROPRIATENESS, BILLING, OR PAYMENT FOR HEALTH CARE
SERVICES BY THIRD PARTY PAYERS;
D. DISPUTES RELATED TO CODING OR DETERMINATION OF DIAGNOSES;
E. DISPUTES RELATED TO PAYMENT ASSOCIATED WITH THE APPROPRIATENESS OF
THE LEVEL OR SETTING FOR THE DELIVERY OF THE HEALTH CARE SERVICE; AND
F. DISPUTES REGARDING PAYMENT RELATED TO THE APPROPRIATENESS OF
SERVICES RENDERED THROUGH THE EMERGENCY DEPARTMENT.
(E) TIMEFRAMES. THE ALTERNATIVE DISPUTE RESOLUTION AGENT SHALL REVIEW
AND RENDER A DECISION ON A DISPUTE WITHIN THIRTY DAYS OF THE RECEIPT OF
ALL REQUESTED INFORMATION. THE DECISION WILL BE BASED UPON A REVIEW OF
THE MATERIALS SUBMITTED BY THE PARTIES AND APPLICABLE LAWS AND REGU-
LATIONS, IF ANY, AND SHALL BE IN WRITING. ANY PAYMENT DETERMINED TO BE
OWED BY A HEALTH CARE PROVIDER OR THIRD PARTY PAYER PURSUANT TO SUCH
DECISION SHALL BE MADE WITHIN THIRTY DAYS OF THE RECEIPT OF THE ALTERNA-
TIVE DISPUTE RESOLUTION AGENT'S DECISION.
(F) INTEREST. WHENEVER THE AMOUNT OF PAYMENT MADE BY A THIRD PARTY
PAYER TO A HEALTH CARE PROVIDER DIFFERS FROM THE AMOUNT OF PAYMENT
DETERMINED IN ACCORDANCE WITH THIS SECTION, INTEREST SHALL BE DUE ON ANY
EXCESS OWED TO THE HEALTH CARE PROVIDER OR THE THIRD PARTY PAYER AT THE
GREATER OF THE RATE EQUAL TO THE RATE SET BY THE COMMISSIONER OF TAXA-
TION AND FINANCE FOR CORPORATE TAXES PURSUANT TO PARAGRAPH ONE OF
SUBSECTION (E) OF SECTION ONE THOUSAND NINETY-SIX OF THE TAX LAW OR
TWELVE PERCENT PER ANNUM, TO BE COMPUTED FROM THE DATE THAT IS THIRTY
DAYS AFTER RECEIPT BY THE PROVIDER OR PAYER OF THE ALTERNATIVE DISPUTE
RESOLUTION AGENT'S DECISION. WHEN THE AMOUNT OF INTEREST DUE ON SUCH A
CLAIM IS LESS THAN TWO DOLLARS, A THIRD PARTY PAYER OR HEALTH CARE
PROVIDER SHALL NOT BE REQUIRED TO PAY INTEREST ON SUCH CLAIM.
(G) FEES. THE COMMISSIONER SHALL ESTABLISH A FEE SCHEDULE NECESSARY TO
SUPPORT THE OPERATION OF THE ALTERNATIVE DISPUTE RESOLUTION SYSTEM. FEES
CHARGED SHALL BE BORNE BY THE PARTY THAT DOES NOT PREVAIL OR PROPOR-
TIONALLY DISTRIBUTED BY DOLLAR VALUE IN CASES OF A MIXED DETERMINATION.
(H) PROHIBITIONS. NO HEALTH CARE PROVIDER OR THIRD PARTY PAYER SHALL
BY CONTRACT, WRITTEN POLICY, OR WRITTEN PROCEDURE PROHIBIT OR RESTRICT
THE USE OF THE ALTERNATIVE DISPUTE RESOLUTION SYSTEM ESTABLISHED HEREIN,
NOR SHALL USE OF THE ALTERNATIVE DISPUTE RESOLUTION SYSTEM BE A PRIOR
REQUIREMENT TO SEEKING ANY OTHER REMEDIES OTHERWISE PERMITTED BY LAW OR
CONTRACT.
(I) THE DECISION OF THE ALTERNATIVE DISPUTE RESOLUTION AGENT SHALL BE
ADMISSIBLE IN ANY COURT PROCEEDING.
(J) THE ALTERNATIVE DISPUTE RESOLUTION AGENT SHALL NOTIFY THE COMMIS-
SIONER AND THE SUPERINTENDENT OF INSURANCE WHEN IT BELIEVES THAT
DISPUTES ADJUDICATED BY IT MAY CONSTITUTE A VIOLATION OF APPLICABLE
STATE OR FEDERAL LAW OR REGULATION OR FAIR BUSINESS PRACTICES. THE
A. 793 4
COMMISSIONER AND SUPERINTENDENT OF INSURANCE SHALL INVESTIGATE SUCH
CASES AND SEEK APPROPRIATE REMEDIES.
(K) A THIRD PARTY PAYER SHALL INCLUDE IN ANY QUARTERLY AND ANNUAL
FILINGS MADE TO THE COMMISSIONER AND THE SUPERINTENDENT OF INSURANCE
INFORMATION RELATED TO THE ALTERNATIVE DISPUTE RESOLUTION PROCESS,
INCLUDING THE NUMBER OF DISPUTES BROUGHT BY IT IN THE TIME PERIOD
COVERED BY THE FILING; THE NUMBER OF DISPUTES BROUGHT AGAINST IT IN THE
TIME PERIOD COVERED BY THE FILING; AND THE DISPOSITION OF SUCH DISPUTES
WITH A STATEMENT OF WHETHER IT PREVAILED OR DID NOT PREVAIL IN WHOLE OR
IN PART.
(1) FOR CLAIM PAYMENT AMOUNTS OR OTHER DISPUTES ELIGIBLE FOR DISPUTE
RESOLUTION PURSUANT TO THIS SECTION, NO INSURED PERSON SHALL HAVE ANY
FINANCIAL LIABILITY FOR ANY PORTION OF THE HEALTH CARE PROVIDER'S BILL,
AND NO HEALTH CARE PROVIDER SHALL BILL AN INSURED OR PURSUE COLLECTION
EFFORTS AGAINST SUCH INSURED FOR THE DIFFERENCE BETWEEN THE HEALTH CARE
PROVIDER'S BILL AND THE THIRD PARTY PAYER'S PAYMENT MADE ON SUCH BILL
EXCEPT FOR DEDUCTIBLES, COINSURANCE BASED ON THE UNDISPUTED PORTION OF
THE BILL, AND FOR UNCOVERED SERVICES; PROVIDED THAT THE DEFINITION OF
UNCOVERED SERVICES SHALL NOT INCLUDE ANY SERVICES OR CLAIMS WHICH ARE IN
DISPUTE BETWEEN THE THIRD PARTY PAYER AND THE PROVIDER. THE PROHIBITION
ON BILLING AND COLLECTION EFFORTS PRESCRIBED BY THIS PARAGRAPH SHALL
REMAIN IN EFFECT UNTIL THE DISPUTE RESOLUTION AGENT RENDERS A DECISION.
S 2. Section 2805-a of the public health law is amended by adding a
new subdivision 5 to read as follows:
5. EVERY GENERAL HOSPITAL SHALL ALSO SUBMIT A QUARTERLY REPORT ON
BILLING PROCEDURES FOR THIRD-PARTY PAYORS AND PAYMENTS. SUCH REPORT
SHALL INCLUDE BUT NOT BE LIMITED TO, A LISTING OF THE NUMBER OF DAYS
FROM THE DATE SERVICES WERE RENDERED UNTIL A CLAIM WAS SUBMITTED TO A
THIRD-PARTY PAYOR FOR SUCH SERVICES, THE NUMBER OF DAYS FROM THE DATE
THAT A CLAIM WAS SUBMITTED UNTIL PAYMENT WAS RECEIVED, THE NUMBER OF
DAYS FROM THE DATE THAT PAYMENT WAS RECEIVED UNTIL THE DATE THAT SUCH
PAYMENT WAS POSTED, AND SUCH OTHER INFORMATION AS THE COMMISSIONER DEEMS
APPROPRIATE.
S 3. Paragraph (g) of subdivision 4 of section 2807-e of the public
health law, as amended by chapter 255 of the laws of 1994, is amended to
read as follows:
(g) The commissioner, in consultation with the superintendent [and the
commissioner of social services] OF INSURANCE, shall establish proce-
dures for requiring third-party payors to accept the electronic
submission of claims information for inpatient or ambulatory care
services made pursuant to the provision of this section. A THIRD-PARTY
PAYOR VIOLATES THIS SUBDIVISION IN EACH INSTANCE THAT THE PAYOR FAILS TO
ACCEPT ELECTRONICALLY A CLAIM THAT A HEALTH CARE PROVIDER ATTEMPTS TO
SUBMIT ELECTRONICALLY. ANY THIRD-PARTY PAYOR VIOLATING THIS SECTION
AFTER JANUARY FIRST, TWO THOUSAND NINE, MUST PAY TWO PERCENT OF THE
FINAL CLAIM AMOUNT TO THE HEALTH CARE PROVIDER AS A PENALTY FOR EACH
VIOLATION. HOWEVER, THE COMMISSIONER SHALL PROMULGATE A SCHEDULE FOR
GRADUAL COMPLIANCE WITH THE PROVISIONS OF THIS PARAGRAPH BY THIRD-PARTY
PAYORS THAT CONTRACT WITH THE DEPARTMENT UNDER SECTION THREE HUNDRED
SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW AND ARE CONTROLLED BY, SPONSORED
BY, OR OTHERWISE AFFILIATED THROUGH A COMMON GOVERNANCE OR THROUGH A
PARENT CORPORATION WITH ONE OR MORE PRIVATE, NOT-FOR-PROFIT OR PUBLIC
GENERAL HOSPITALS OR DIAGNOSTIC AND TREATMENT CENTERS LICENSED PURSUANT
TO THIS ARTICLE. SUCH SCHEDULE SHALL BE BASED ON THE MANAGEMENT INFOR-
MATION SYSTEMS CAPACITY AND ENROLLMENT OF SUCH PAYORS AND SHALL REQUIRE
A. 793 5
COMPLIANCE WITH THIS PARAGRAPH BY NO LATER THAN JULY FIRST, TWO THOUSAND
TEN.
S 4. Subdivision 21 of section 364-j of the social services law is
amended by adding a new paragraph (g) to read as follows:
(G) THE DEPARTMENT OF HEALTH SHALL, BY MARCH FIRST, TWO THOUSAND TEN
AND ANNUALLY BY DECEMBER FIRST THEREAFTER, ANNOUNCE THE PREMIUM RATES
EFFECTIVE FOR THE NEXT RATE YEAR. THE DEPARTMENT OF HEALTH SHALL
FURTHER COMMENCE PAYMENT OF THE NEW RATES ON APRIL FIRST, TWO THOUSAND
TEN AND ANNUALLY ON JANUARY FIRST THEREAFTER. NOTWITHSTANDING ANY LAW,
RULE OR REGULATION TO THE CONTRARY, IN THE EVENT THAT THE DEPARTMENT OF
HEALTH FAILS TO COMMENCE PAYMENT OF THE NEW RATES BY APRIL FIRST, TWO
THOUSAND TEN OR BY JANUARY FIRST THEREAFTER, THE DEPARTMENT OF HEALTH
SHALL PAY INTEREST ON ANY INCREASE IN THE RATES OVER THE PRIOR YEAR'S
RATES AT THE INTEREST RATE SPECIFIED IN SECTION ONE HUNDRED
SEVENTY-NINE-G OF THE STATE FINANCE LAW.
S 5. The opening paragraph of subparagraph (i) of paragraph (a) of
subdivision 5 of section 4900 of the public health law, as amended by
chapter 558 of the laws of 1999, is amended to read as follows:
AN INDIVIDUAL health care [procedures, treatments or services] PROCE-
DURE, TREATMENT OR UNIT OF SERVICE FOR WHICH A UTILIZATION REVIEW AGENT
CHOOSES TO UNIQUELY DETERMINE MEDICAL NECESSITY REGARDLESS OF WHETHER
THE HEALTH CARE PROCEDURE, TREATMENT OR UNIT OF SERVICE IS PART OF A
COURSE OF TREATMENT CONSISTING OF MULTIPLE PROCEDURES, TREATMENTS OR
UNITS OF SERVICE
S 6. Subparagraph (A) of paragraph (b) of subdivision 5 of section
4900 of the public health law, as amended by chapter 558 of the laws of
1999, is amended to read as follows:
(A) [services] AN INDIVIDUAL HEALTH CARE PROCEDURE, TREATMENT OR UNIT
OF SERVICE provided within a clinical trial FOR WHICH A UTILIZATION
REVIEW AGENT CHOOSES TO UNIQUELY DETERMINE MEDICAL NECESSITY REGARDLESS
OF WHETHER THE HEALTH CARE PROCEDURE, TREATMENT OR UNIT OF SERVICE IS
PART OF A COURSE OF TREATMENT CONSISTING OF MULTIPLE PROCEDURES, TREAT-
MENTS, OR UNITS OF SERVICE, and
S 7. Subparagraph (A) of paragraph 1 of subsection (e) of section 4900
of the insurance law, as amended by chapter 558 of the laws of 1999, is
amended to read as follows:
(A) AN INDIVIDUAL health care [procedures, treatments or services]
PROCEDURE, TREATMENT OR UNIT OF SERVICE FOR WHICH A UTILIZATION REVIEW
AGENT CHOOSES TO UNIQUELY DETERMINE MEDICAL NECESSITY REGARDLESS OF
WHETHER THE HEALTH CARE PROCEDURE, TREATMENT OR UNIT OF SERVICE IS PART
OF A COURSE OF TREATMENT CONSISTING OF MULTIPLE PROCEDURES, TREATMENTS
OR UNITS OF SERVICE
S 8. Subparagraph (A) of paragraph 2 of subsection (e) of section 4900
of the insurance law, as amended by chapter 558 of the laws of 1999, is
amended to read as follows:
(A) [services] AN INDIVIDUAL HEALTH CARE PROCEDURE, TREATMENT OR UNIT
OF SERVICE provided within a clinical trial FOR WHICH A UTILIZATION
REVIEW AGENT CHOOSES TO UNIQUELY DETERMINE MEDICAL NECESSITY REGARDLESS
OF WHETHER THE HEALTH CARE PROCEDURE, TREATMENT OR UNIT OF SERVICE IS
PART OF A COURSE OF TREATMENT CONSISTING OF MULTIPLE PROCEDURES, TREAT-
MENTS, OR UNITS OF SERVICE, and
S 9. Section 4900 of the public health law is amended by adding a new
subdivision 7-g to read as follows:
7-G. "RETROSPECTIVE ADVERSE DETERMINATION" MEANS AN ADVERSE DETERMI-
NATION THAT AN ENROLLEE, AN ENROLLEE'S DESIGNEE, OR AN ENROLLEE'S HEALTH
CARE PROVIDER RECEIVES FROM A UTILIZATION REVIEW AGENT AFTER THE ENROL-
A. 793 6
LEE HAS RECEIVED A HEALTH CARE SERVICE, REGARDLESS OF WHEN THE UTILIZA-
TION REVIEW AGENT BEGAN ITS REVIEW OF THE SERVICE.
S 10. Section 4900 of the insurance law is amended by adding a new
subsection (g-7) to read as follows:
(G-7) "RETROSPECTIVE ADVERSE DETERMINATION" MEANS AN ADVERSE DETERMI-
NATION THAT AN ENROLLEE, AN ENROLLEE'S DESIGNEE, OR AN ENROLLEE'S HEALTH
CARE PROVIDER RECEIVES FROM A UTILIZATION REVIEW AGENT AFTER THE ENROL-
LEE HAS RECEIVED A HEALTH CARE SERVICE, REGARDLESS OF WHEN THE UTILIZA-
TION REVIEW AGENT BEGAN ITS REVIEW OF THE SERVICE.
S 11. Paragraph (b) of subdivision 1 of section 4902 of the public
health law, as amended by chapter 586 of the laws of 1998, is amended to
read as follows:
(b) Development of written policies and procedures that govern all
aspects of the utilization review process and a requirement that a
utilization review agent shall maintain and make available to enrollees
and health care providers a written description of such procedures
including procedures to appeal an adverse determination together with a
description, jointly promulgated by the commissioner and the superinten-
dent of insurance as required pursuant to subdivision five of section
forty-nine hundred fourteen of this article, of the external appeal
process established pursuant to title two of this article and the time
frames for such appeals. THE UTILIZATION REVIEW AGENT SHALL NOTIFY
PROVIDERS AND ENROLLEES AT LEAST TWENTY BUSINESS DAYS BEFORE IT CHANGES
ITS POLICIES AND PROCEDURES;
S 12. Paragraph 2 of subsection (a) of section 4902 of the insurance
law, as amended by chapter 586 of the laws of 1998, is amended to read
as follows:
(2) Development of written policies and procedures that govern all
aspects of the utilization review process and a requirement that a
utilization review agent shall maintain and make available to insureds
and health care providers a written description of such procedures
including procedures to appeal an adverse determination together with a
description, jointly promulgated by the superintendent and the commis-
sioner of health as required pursuant to subsection (e) of section four
thousand nine hundred fourteen of this article, of the external appeal
process established pursuant to title two of this article and the time
frames for such appeals. THE UTILIZATION REVIEW AGENT SHALL NOTIFY
PROVIDERS AND ENROLLEES AT LEAST TWENTY BUSINESS DAYS BEFORE IT CHANGES
ITS POLICIES AND PROCEDURES;
S 13. Paragraph (c) of subdivision 1 of section 4902 of the public
health law, as added by chapter 705 of the laws of 1996, is amended to
read as follows:
(c) Utilization of written clinical review criteria developed pursuant
to a utilization review plan CONSISTENT WITH THE REQUIREMENTS OF SECTION
FORTY-NINE HUNDRED TEN OF THIS ARTICLE; MADE AVAILABLE TO ENROLLEES AND
HEALTH CARE PROVIDERS, UPON REQUEST, IN SUFFICIENT SPECIFICITY TO
APPRISE THE PROVIDER OF EVERY CASE-SPECIFIC CLINICAL REVIEW CRITERION
AND STANDARD USED IN THE REVIEW PROCESS; WITH ADVANCE NOTICE OF AT LEAST
TWENTY BUSINESS DAYS TO CONTRACTED PROVIDERS OF CHANGES TO SUCH CRITERIA
AND STANDARDS;
S 14. Paragraph 3 of subsection (a) of section 4902 of the insurance
law, as added by chapter 705 of the laws of 1996, is amended to read as
follows:
(3) Utilization of written clinical review criteria developed pursuant
to a utilization review plan CONSISTENT WITH THE REQUIREMENTS OF SECTION
FOUR THOUSAND NINE HUNDRED TEN OF THIS ARTICLE; MADE AVAILABLE, UPON
A. 793 7
REQUEST, TO ENROLLEES AND HEALTH CARE PROVIDERS IN SUFFICIENT SPECIFICI-
TY TO APPRISE THE PROVIDER OF EVERY CASE-SPECIFIC CLINICAL REVIEW CRITE-
RION AND STANDARD USED IN THE REVIEW PROCESS; WITH ADVANCE NOTICE OF AT
LEAST TWENTY BUSINESS DAYS TO CONTRACTED PROVIDERS OF CHANGES TO SUCH
CRITERIA AND STANDARDS;
S 15. Paragraph (h) of subdivision 1 of section 4902 of the public
health law, as added by chapter 705 of the laws of 1996, is amended to
read as follows:
(h) Establishment of a requirement that emergency services rendered to
an enrollee shall not be subject to prior authorization OR NOTICE
REQUIREMENTS OF FEWER THAN FIVE DAYS FOLLOWING RECEIPT OF THESE
SERVICES, UNLESS OTHERWISE AGREED TO BY A HEALTH CARE PLAN AND A HEALTH
CARE PROVIDER, nor shall reimbursement for such services be denied [on
retrospective review; provided, however,] FOR ANY REASON EXCEPT that
such services [are] WERE NOT medically necessary to stabilize or treat
an emergency condition.
S 16. Paragraph 8 of subsection (a) of section 4902 of the insurance
law, as added by chapter 705 of the laws of 1996, is amended to read as
follows:
(8) Establishment of a requirement that emergency services rendered to
an insured shall not be subject to prior authorization OR NOTICE
REQUIREMENTS OF FEWER THAN FIVE DAYS FOLLOWING RECEIPT OF THESE
SERVICES, UNLESS OTHERWISE AGREED TO BY A HEALTH CARE PLAN AND A HEALTH
CARE PROVIDER, nor shall reimbursement for such services be denied [on
retrospective review; provided, however,] FOR ANY REASON EXCEPT that
such services [are] WERE NOT medically necessary to stabilize or treat
an emergency condition.
S 17. 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 NOT REQUIRE AN ENROLLEE, AN
ENROLLEE'S DESIGNEE OR AN ENROLLEE'S HEALTH CARE PROVIDER TO REQUEST
PRE-AUTHORIZATION FOR HEALTH CARE SERVICES MORE THAN SEVEN BUSINESS DAYS
IN ADVANCE OF THE DATE ON WHICH THE SERVICES ARE PROPOSED TO BE
PROVIDED. A utilization review agent shall make a utilization review
determination involving [health care] SUCH services [which require pre-
authorization] and provide notice of [a] ITS determination to the enrol-
lee 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 information.
S 18. Subdivision 7 of section 4905 of the public health law, as added
by chapter 705 of the laws of 1996, is amended to read as follows:
7. When making prospective, concurrent and retrospective determi-
nations, utilization review agents shall collect only such information
as is necessary to make such determination and shall not routinely
require health care providers to numerically code diagnoses or proce-
dures to be considered for certification or routinely request copies of
medical records of all patients reviewed. During prospective or concur-
rent review, copies of medical records shall only be required when
necessary to verify that the health care services subject to such review
are medically necessary. In such cases, only the necessary or relevant
sections of the medical record shall be required. A utilization review
agent may request copies of partial or complete medical records retros-
pectively. [This subdivision shall not apply to health maintenance
organizations licensed pursuant to article forty-three of the insurance
law or certified pursuant to article forty-four of this chapter.]
A. 793 8
S 19. Section 4905 of the public health law is amended by adding a new
subdivision 16 to read as follows:
16. A PRE-AUTHORIZATION APPROVAL GRANTED BY A UTILIZATION REVIEW AGENT
IS A BINDING COMMITMENT TO MAKE PAYMENT FOR SPECIFIC SERVICES PERFORMED
AND PRE-AUTHORIZED, EXCEPT IN CASES WHERE THE SERVICES WERE RENDERED TO
AN INDIVIDUAL NOT ENROLLED IN A PLAN AT THE TIME SERVICES WERE RENDERED,
OR WHEN THERE IS A REASONABLE BASIS SUPPORTED BY SPECIFIC INFORMATION
AVAILABLE FOR REVIEW BY THE SUPERINTENDENT OF INSURANCE THAT SUCH
APPROVAL WAS OBTAINED FRAUDULENTLY. IN THE EVENT THAT MORE THAN ONE
PAYOR IS RESPONSIBLE FOR PAYMENT FOR HEALTH CARE SERVICES RENDERED,
PRE-AUTHORIZATION SHALL NOT PRECLUDE ANY CLAIM BY THE PAYOR FOR INDEMNI-
FICATION OR CONTRIBUTION FROM OTHER PAYORS RESPONSIBLE FOR PAYMENT.
SPECIFIC SERVICES MAY INCLUDE SPECIFIC PROCEDURES, SITE OF SERVICE,
INPATIENT ADMISSION OR A TREATMENT PLAN FOR A CHRONIC PATIENT.
S 20. The public health law is amended by adding a new section 4908-a
to read as follows:
S 4908-A. ENFORCEMENT. IN ADDITION TO ANY OTHER POWERS CONFERRED ON
THE COMMISSIONER TO ENFORCE THIS CHAPTER, THE COMMISSIONER MAY TAKE THE
FOLLOWING ACTIONS WHEN ENTITIES SUBJECT TO THIS TITLE FAIL TO COMPLY
WITH THE PROVISIONS OF THIS TITLE.
1. THE COMMISSIONER MAY REQUIRE AN ENTITY TO SUBMIT A CORRECTIVE
ACTION PLAN AND PERIODIC UPDATES UNTIL THE COMMISSIONER IS SATISFIED
THAT THE ENTITY IS IN COMPLIANCE AND HAS ADOPTED THE NECESSARY PROCE-
DURES TO ENSURE FUTURE COMPLIANCES.
2. THE COMMISSIONER MAY IMPOSE A FINE OF UP TO ONE THOUSAND DOLLARS
FOR EACH VIOLATION OF THIS TITLE.
3. THE COMMISSIONER MAY RENEW WITH RESTRICTIONS OR REFUSE TO RENEW THE
REGISTRATION OF A UTILIZATION REVIEW AGENT.
4. THE COMMISSIONER MAY REVOKE THE REGISTRATION OF A UTILIZATION
REVIEW AGENT.
5. THE COMMISSIONER MAY RESTRICT THE REGISTRATION OF A UTILIZATION
REVIEW AGENT TO PERFORM PARTICULAR TYPES OF UTILIZATION REVIEW UNTIL THE
AGENT COMPLIES WITH THIS TITLE.
S 21. 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 NOT REQUIRE AN ENROLLEE, AN
ENROLLEE'S DESIGNEE OR AN ENROLLEE'S HEALTH CARE PROVIDER TO REQUEST
PRE-AUTHORIZATION FOR HEALTH CARE SERVICES MORE THAN SEVEN BUSINESS DAYS
IN ADVANCE OF THE DATE ON WHICH THE SERVICES ARE PROPOSED TO BE
PROVIDED. A utilization review agent shall make a utilization review
determination involving [health care] SUCH services [which require pre-
authorization] and provide notice of [a] ITS determination to the
insured or insured's designee and the insured's health care provider by
telephone and in writing within three business days of receipt of the
necessary information.
S 22. Section 4905 of the insurance law is amended by adding a new
subsection (p) to read as follows:
(P) A PRE-AUTHORIZATION APPROVAL GRANTED BY A UTILIZATION REVIEW AGENT
IS A BINDING COMMITMENT TO MAKE PAYMENT FOR SPECIFIC SERVICES PERFORMED
AND PRE-AUTHORIZED, EXCEPT IN CASES WHERE THE SERVICES WERE RENDERED TO
AN INDIVIDUAL NOT ENROLLED IN A PLAN AT THE TIME SERVICES WERE DELIV-
ERED, OR WHEN THERE IS A REASONABLE BASIS SUPPORTED BY SPECIFIC INFORMA-
TION AVAILABLE FOR REVIEW BY THE SUPERINTENDENT THAT SUCH APPROVAL WAS
OBTAINED FRAUDULENTLY. IN THE EVENT THAT MORE THAN ONE PAYOR IS RESPON-
SIBLE FOR PAYMENT FOR HEALTH CARE SERVICES RENDERED, PRE-AUTHORIZATION
SHALL NOT PRECLUDE ANY CLAIM BY THE PAYOR FOR INDEMNIFICATION OR
A. 793 9
CONTRIBUTION FROM OTHER PAYORS RESPONSIBLE FOR PAYMENT. SPECIFIC
SERVICES MAY INCLUDE SPECIFIC PROCEDURES, SITE OF SERVICE, INPATIENT
ADMISSION OR A TREATMENT PLAN FOR A CHRONIC PATIENT.
S 23. The insurance law is amended by adding a new section 4908-a to
read as follows:
S 4908-A. ENFORCEMENT. IN ADDITION TO ANY OTHER POWERS CONFERRED ON
THE SUPERINTENDENT TO ENFORCE THIS CHAPTER, THE SUPERINTENDENT MAY TAKE
THE FOLLOWING ACTIONS WHEN ENTITIES SUBJECT TO THIS TITLE FAIL TO COMPLY
WITH THE PROVISIONS OF THIS TITLE.
(A) THE SUPERINTENDENT MAY REQUIRE AN ENTITY TO SUBMIT A CORRECTIVE
ACTION PLAN AND PERIODIC UPDATES UNTIL THE SUPERINTENDENT IS SATISFIED
THAT THE ENTITY COMPLIES.
(B) THE SUPERINTENDENT MAY IMPOSE A FINE OF UP TO ONE THOUSAND DOLLARS
FOR EACH VIOLATION OF THIS TITLE.
(C) THE SUPERINTENDENT MAY RENEW WITH RESTRICTIONS OR REFUSE TO RENEW
THE REGISTRATION OF A UTILIZATION REVIEW AGENT.
(D) THE SUPERINTENDENT MAY REVOKE THE REGISTRATION OF A UTILIZATION
REVIEW AGENT.
(E) THE SUPERINTENDENT MAY RESTRICT THE REGISTRATION OF A UTILIZATION
REVIEW AGENT TO PERFORM PARTICULAR TYPES OF UTILIZATION REVIEW UNTIL THE
AGENT COMPLIES WITH THIS TITLE.
S 24. Section 2601 of the insurance law, paragraphs 4 and 5 of
subsection (a) as amended by chapter 547 of the laws of 1997 and para-
graph 6 of subsection (a) as amended by chapter 388 of the laws of 2008,
is amended to read as follows:
S 2601. Unfair claim settlement practices; penalties. (a) No insurer,
CORPORATION, OR ORGANIZATION LICENSED, ORGANIZED, OR CERTIFIED PURSUANT
TO THIS CHAPTER OR ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW AND doing
business in this state shall engage in unfair claim settlement prac-
tices. Any of the following acts by [an insurer] SUCH ENTITIES, if
committed without just cause and performed with such frequency as to
indicate a general business practice, shall constitute unfair claim
settlement practices:
(1) knowingly misrepresenting to claimants pertinent facts or policy
provisions relating to coverages at issue;
(2) failing to acknowledge with reasonable promptness pertinent commu-
nications as to claims arising under its policies;
(3) failing to adopt and implement reasonable standards for the prompt
investigation of claims arising under its policies;
(4) not attempting in good faith to effectuate prompt, fair and equi-
table settlements of claims submitted in which liability has become
reasonably clear, except where there is a reasonable basis supported by
specific information available for review by the department that the
claimant has caused the loss to occur by arson. After receiving a prop-
erly executed proof of loss, the insurer shall advise the claimant of
acceptance or denial of the claim within thirty working days;
(5) compelling policyholders to institute suits to recover amounts due
under its policies by offering substantially less than the amounts ulti-
mately recovered in suits brought by them; [or]
(6) failing to promptly disclose coverage pursuant to subsection (d)
or subparagraph (A) of paragraph two of subsection (f) of section three
thousand four hundred twenty of this chapter;
(7) FAILING TO COMPLY WITH SECTION THREE THOUSAND TWO HUNDRED TWENTY-
FOUR-A OF THIS CHAPTER;
A. 793 10
(8) FAILING TO ABIDE BY THE TERMS OF A CONTRACT WITH A HEALTH CARE
PROVIDER, INCLUDING FAILURE TO MAKE PAYMENT AT THE CONTRACTED RATES, OR
STATE OR FEDERAL LAWS OR REGULATIONS;
(9) REQUESTING MEDICAL RECORDS FROM HEALTH CARE PROVIDERS TO EVALUATE
CLAIMS AT A RATE OR WITH SUCH FREQUENCY WHICH, UPON INVESTIGATION BY THE
SUPERINTENDENT, IS FOUND NOT TO BE JUSTIFIED; OR
(10) DENYING PAYMENT TO HEALTH CARE PROVIDERS, IN WHOLE OR IN PART,
WHEN, UPON INVESTIGATION BY THE SUPERINTENDENT, MORE THAN FIFTY PER
CENTUM OF THE CLAIMS DENIALS ARE OVERTURNED ON APPEAL PURSUANT TO ARTI-
CLE FORTY-NINE OF THE PUBLIC HEALTH LAW, ARTICLE FORTY-NINE OF THIS
CHAPTER OR SECTION TWO HUNDRED SIX OF THE PUBLIC HEALTH LAW, OR IN A
JUDICIAL PROCEEDING OR ARBITRATION.
(b) Evidence as to numbers and types of complaints to the department
against [an insurer] SUCH ENTITIES and as to the department's complaint
experience with other [insurers] ENTITIES writing similar lines of
insurance shall be admissible in evidence in any administrative or judi-
cial proceeding under this section or article twenty-four or seventy-
four of this chapter, but, EXCEPT FOR PARAGRAPHS SEVEN, EIGHT, NINE AND
TEN OF SUBSECTION (A) OF THIS SECTION, no [insurer] ENTITY shall be
deemed in violation of this section solely by reason of the numbers and
types of such complaints.
(c) (1) If it is found, after notice and an opportunity to be heard,
that an insurer has violated this section, each instance of noncompli-
ance with subsection (a) [hereof] OF THIS SECTION may be treated as a
separate violation of this section for purposes of ordering a monetary
penalty pursuant to subsection (b) of section one hundred nine of this
chapter. A violation of this section shall not be a misdemeanor.
(2) IF IT IS FOUND, AFTER NOTICE AND AN OPPORTUNITY TO BE HEARD, THAT
AN INSURER OR AN ORGANIZATION OR CORPORATION LICENSED OR CERTIFIED
PURSUANT TO ARTICLE FORTY-THREE OF THIS CHAPTER OR ARTICLE FORTY-FOUR OF
THE PUBLIC HEALTH LAW IS IN VIOLATION OF PARAGRAPHS SEVEN, EIGHT, NINE
OR TEN OF SUBSECTION (A) OF THIS SECTION WITH RESPECT TO A PARTICULAR
HEALTH CARE PROVIDER, THE SUPERINTENDENT SHALL REQUIRE THE INSURER,
ORGANIZATION, OR CORPORATION TO ESTABLISH AN INTERIM PAYMENT SYSTEM THAT
MAKES PAYMENT TO THE AFFECTED PROVIDER FOR HEALTH CARE SERVICES.
(A) SUCH INTERIM PAYMENT SYSTEM SHALL CONSIST OF UNIFORM PAYMENT
AMOUNTS MADE ON A WEEKLY BASIS TO THE PROVIDER OF SERVICES BASED ON THE
MOST RECENTLY AVAILABLE INFORMATION ON THE ACTUAL AVERAGE WEEKLY PAYMENT
AMOUNTS TO THE HEALTH CARE PROVIDER, CALCULATED OVER A SIX MONTH PERIOD,
INCREASED BY AN APPROPRIATE TREND FACTOR. PAYMENT AMOUNTS SHALL BE
RETROACTIVELY ADJUSTED TO REFLECT ACTUAL AMOUNTS OWED PURSUANT TO A
CLAIM RECONCILIATION PROCESS. RETROSPECTIVE ADJUSTMENTS FOR OVERPAYMENT
TO PROVIDERS SHALL BE MADE OVER THE SAME NUMBER OF PAYMENTS AS WERE
UTILIZED IN THE RECONCILIATION CALCULATION. RETROSPECTIVE ADJUSTMENTS
FOR UNDERPAYMENT TO PROVIDERS SHALL BE MADE IN THE NEXT PAYMENT.
(B) THE SUPERINTENDENT SHALL REQUIRE AN INTERIM PAYMENT SYSTEM ONLY
FOR AN ENTITY LICENSED OR CERTIFIED PURSUANT TO ARTICLE TWENTY-EIGHT,
THIRTY-SIX OR FORTY OF THE PUBLIC HEALTH LAW, A FACILITY LICENSED PURSU-
ANT TO ARTICLE NINETEEN OR THIRTY-ONE OF THE MENTAL HYGIENE LAW, A
DISPENSER OR PROVIDER OF PHARMACEUTICAL PRODUCTS, SERVICES OR DURABLE
MEDICAL EQUIPMENT OR AN INDEPENDENT PRACTICE ASSOCIATION WHICH IS
AUTHORIZED TO FURNISH HEALTH CARE SERVICES UNDER A CONTRACT WITH AN
INSURER, CORPORATION OR ORGANIZATION. THE INTERIM PAYMENT SYSTEM SHALL
BE MAINTAINED FOR SUCH TIME AS SPECIFIED BY THE SUPERINTENDENT AND AT
LEAST UNTIL SUCH TIME THAT THE INSURER, ORGANIZATION, OR CORPORATION
DEMONSTRATES TO THE SATISFACTION OF THE SUPERINTENDENT THAT IT HAS IN
A. 793 11
PLACE SYSTEMS THAT WILL ENSURE THAT IT NO LONGER WILL CONSISTENTLY
VIOLATE THE PROVISIONS OF THIS SECTION OR THE TERMS OF A CONTRACT WITH
A HEALTH CARE PROVIDER RELATED TO PAYMENT AND MEDICAL REVIEW.
S 25. Section 3224-a of the insurance law, as amended by chapter 666
of the laws of 1997, is amended to read as follows:
S 3224-a. Standards for prompt, fair and equitable settlement of
claims for health care and payments for health care services. In the
processing of all health care claims submitted under contracts or agree-
ments issued or entered into pursuant to articles thirty-two, forty-two
and forty-three of this chapter and article forty-four of the public
health law and all bills for health care services rendered by health
care providers pursuant to such contracts or agreements, any insurer or
organization or corporation licensed or certified pursuant to article
forty-three of this chapter or article forty-four of the public health
law shall adhere to the following standards:
(a) Except in a case where the obligation of an insurer or an organ-
ization or corporation licensed or certified pursuant to article forty-
three of this chapter or article forty-four of the public health law to
pay a claim submitted by a policyholder or person covered under such
policy or make a payment to a health care provider is not reasonably
clear, or when there is a reasonable basis supported by specific infor-
mation available for review by the superintendent that such claim or
bill for health care services rendered was submitted fraudulently, such
insurer or organization or corporation shall pay the claim to a policy-
holder or covered person or make a payment to a health care provider
within [forty-five days of receipt of a claim or bill for services
rendered.]:
(1) FIFTEEN BUSINESS DAYS OF RECEIPT OF A CLAIM OR BILL FOR SERVICES
RENDERED WHICH IS TRANSMITTED ELECTRONICALLY WITHIN THIRTY DAYS OF THE
DATE THE SERVICES WERE RENDERED, OR IN THE CASE OF INPATIENT CARE, THE
DATE OF DISCHARGE, IN THE CORRECT AMOUNT PROVIDED FOR UNDER THE
CONTRACT, IF A CONTRACT APPLIES; OR
(2) THIRTY DAYS OF RECEIPT OF A CLAIM OR BILL FOR SERVICES RENDERED
WHICH IS SUBMITTED IN WRITING OR AN ELECTRONIC TRANSMISSION WHICH DOES
NOT COMPLY WITH PARAGRAPH ONE OF THIS SUBSECTION.
(b) (1) In a case where the obligation of an insurer or an organiza-
tion or corporation licensed or certified pursuant to article forty-
three of this chapter or article forty-four of the public health law to
pay a claim or make a payment for health care services rendered is not
reasonably clear due to a good faith dispute regarding the eligibility
of a person for coverage, the liability of another insurer or corpo-
ration or organization for all or part of the claim, the amount of the
claim, the benefits covered under a contract or agreement, or the manner
in which services were accessed or provided, an insurer or organization
or corporation shall pay any undisputed portion of the claim in accord-
ance with this subsection and notify the policyholder, covered person
[or] AND health care provider in writing within thirty calendar days of
the receipt of the claim:
[(1)] (A) that it is not obligated to pay the claim or make the
medical payment, IN WHOLE OR IN PART, stating the specific reasons why
it is not liable; or
[(2)] (B) to request all additional information needed to determine
liability to pay the claim or make the health care payment, IN WHOLE OR
IN PART, AND
(C) THE AMOUNT THAT IS TO BE PAID BY THE INSURER OR ORGANIZATION OR
CORPORATION LICENSED OR CERTIFIED PURSUANT TO ARTICLE FORTY-THREE OF
A. 793 12
THIS CHAPTER OR ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW AND THE
AMOUNTS FOR WHICH PAYMENT IS DENIED OR IN DISPUTE, SHOWING THE CALCU-
LATIONS FOR PAYMENT, BY SERVICE PROVIDED, INCLUDING CO-PAYMENTS, DEDUCT-
IBLES, SURCHARGES AND FEE-SCHEDULES.
(2) Upon receipt of the information requested in [paragraph two]
SUBPARAGRAPH (B) OF PARAGRAPH ONE of this subsection or an appeal of a
claim or bill for health care services denied pursuant to SUBPARAGRAPH
(A) OF paragraph one of this subsection, an insurer or organization or
corporation licensed pursuant to article forty-three of this chapter or
article forty-four of the public health law shall [comply with
subsection (a) of this section] MAKE PAYMENT OR NOTIFY THE POLICYHOLDER,
COVERED PERSON AND HEALTH CARE PROVIDER OF A FINAL DETERMINATION TO DENY
PAYMENT STATING THE SPECIFIC REASONS WHY IT IS NOT LIABLE WITHIN FIFTEEN
CALENDAR DAYS OF THE RECEIPT OF THE INFORMATION REQUESTED.
(c) [Each] AT LEAST ANNUALLY, THE SUPERINTENDENT SHALL COLLECT AND
PUBLISH THE POSTAL AND ELECTRONIC ADDRESSES TO WHICH POLICYHOLDERS,
COVERED PERSONS AND HEALTH CARE PROVIDERS MAY SUBMIT CLAIMS, ADDITIONAL
INFORMATION AND APPEALS TO EACH INSURER, CORPORATION AND ORGANIZATION.
THIS INFORMATION SHALL INCLUDE ADDRESSES FOR ANY ELECTRONIC TRANSACTIONS
VENDOR OR ANY SUBCONTRACTORS THAT PROCESS CLAIMS ON BEHALF OF THE INSUR-
ER, CORPORATION, OR ORGANIZATION AND INSTRUCTIONS ON WHICH CLAIMS,
INFORMATION OR APPEALS SHOULD BE SUBMITTED TO WHICH ADDRESS.
(D) (1) UNLESS OTHERWISE AGREED TO IN A CONTRACT BETWEEN AN INSURER,
CORPORATION OR ORGANIZATION AND A HEALTH CARE PROVIDER, AN INSURER,
CORPORATION OR ORGANIZATION SHALL ALLOW A HEALTH CARE PROVIDER DESIG-
NATED IN SUBPARAGRAPH (B) OF PARAGRAPH TWO OF SUBSECTION (C) OF SECTION
TWO THOUSAND SIX HUNDRED ONE OF THIS CHAPTER AT LEAST ONE HUNDRED TWENTY
DAYS, AND ANY OTHER HEALTH CARE PROVIDER AT LEAST SIX MONTHS, TO SUBMIT
A CLAIM AFTER THE PROVIDER LEARNS THAT THE INSURER, CORPORATION OR
ORGANIZATION HAD, AT THE TIME SERVICES WERE DELIVERED, A CONTRACT AND AN
OBLIGATION TO REIMBURSE THE CLAIMS FOR HEALTH SERVICES THAT WERE
RECEIVED BY A POLICYHOLDER OR COVERED PERSON OR AFTER THE PROVIDER HAS
RECEIVED A DENIAL, IN WHOLE OR IN PART, FROM ANOTHER ENTITY BELIEVED TO
HAVE AN OBLIGATION TO PAY CLAIMS FOR HEALTH SERVICES RECEIVED BY THE
POLICYHOLDER OR COVERED PERSON. AN INSURER, CORPORATION OR ORGANIZATION
SHALL ALLOW A POLICYHOLDER OR COVERED PERSON AT LEAST SIX MONTHS TO
SUBMIT A CLAIM AFTER A HEALTH CARE SERVICE WAS PROVIDED OR AFTER THE
POLICYHOLDER OR COVERED PERSON RECEIVED A DENIAL FROM ANOTHER ENTITY
THAT PROVIDES HEALTH BENEFITS TO HIM OR HER.
(2) AN INSURER, CORPORATION OR ORGANIZATION SHALL ALLOW POLICYHOLDERS,
COVERED PERSONS, AND HEALTH CARE PROVIDERS AT LEAST THIRTY CALENDAR DAYS
TO SUBMIT ANY ADDITIONAL INFORMATION IT REQUESTED PURSUANT TO SUBPARA-
GRAPH (B) OF PARAGRAPH ONE OF SUBSECTION (B) OF THIS SECTION OR THAT IT
REQUESTED TO RESPOND TO AN APPEAL FILED BY A POLICYHOLDER, COVERED
PERSON, OR HEALTH CARE PROVIDER PURSUANT TO THIS SUBSECTION.
(3) PURSUANT TO THIS SUBSECTION, AN INSURER, CORPORATION OR ORGANIZA-
TION SHALL ALLOW A POLICYHOLDER, COVERED PERSON OR HEALTH CARE PROVIDER
AT LEAST FORTY-FIVE DAYS TO APPEAL, AFTER RECEIPT OF A DENIAL OF A CLAIM
OR A BILL PURSUANT TO SUBPARAGRAPH (A) OF PARAGRAPH ONE OF SUBSECTION
(B) OF THIS SECTION.
(4) THE DATE OF RECEIPT OF A CLAIM OR ADDITIONAL INFORMATION SHALL BE,
WITH RESPECT TO CLAIMS OR INFORMATION DELIVERED BY THE UNITED STATES
POSTAL SERVICE OR OTHER DELIVERY SERVICE, THE DATE OF DELIVERY AT THE
SITE SPECIFIED BY THE INSURER, CORPORATION OR ORGANIZATION WITH THE
SUPERINTENDENT PURSUANT TO SUBSECTION (C) OF THIS SECTION; OR SHALL BE,
WITH RESPECT TO CLAIMS OR INFORMATION DELIVERED ELECTRONICALLY, THE DATE
A. 793 13
OF ELECTRONIC ACKNOWLEDGMENT FROM THE INSURER, CORPORATION OR ORGANIZA-
TION OR ITS ELECTRONIC TRANSACTIONS VENDOR. AN INSURER, CORPORATION,
ORGANIZATION OR ANY AGENT ACTING ON BEHALF OF SUCH ENTITY WHO ACCEPTS
AND RECEIVES CLAIMS IN ELECTRONIC FORMAT SHALL, WITHIN FORTY-EIGHT HOURS
AFTER THE RECEIPT OF SUCH A CLAIM, TRANSMIT ELECTRONICALLY AN ACKNOWL-
EDGMENT OF THE RECEIPT OF SUCH A CLAIM TO THE HEALTH CARE PROVIDER OR
ENTITY WHICH SUBMITTED THE CLAIM.
(5) NO INSURER, CORPORATION OR ORGANIZATION SHALL SEEK TO RECOVER FROM
A HEALTH CARE PROVIDER, OR REDUCE PAYMENT TO A HEALTH CARE PROVIDER, ANY
PORTION OF A PAYMENT BEYOND THE DATE WHICH IS ONE YEAR AFTER THE DATE OF
PAYMENT, EXCEPT WHEN THERE IS A REASONABLE BASIS SUPPORTED BY SPECIFIC
INFORMATION AVAILABLE FOR REVIEW BY THE SUPERINTENDENT THAT SUCH PAYMENT
WAS OBTAINED FRAUDULENTLY.
(E)(1) EXCEPT AS PROVIDED IN PARAGRAPH FOUR OF THIS SUBSECTION, EACH
claim or bill for health care services processed in violation of this
section shall constitute a separate violation. In addition to the penal-
ties provided in this chapter, any insurer or organization or corpo-
ration that fails to adhere to the standards contained in this section
shall be obligated to pay to the health care provider or person submit-
ting the claim, in full settlement of the claim or bill for health care
services, the amount of the claim or health care payment plus interest
on the amount of such claim or health care payment of the greater of the
rate equal to the rate set by the commissioner of taxation and finance
for corporate taxes pursuant to paragraph one of subsection (e) of
section one thousand ninety-six of the tax law or twelve percent per
annum, to be computed from the date the claim or health care payment was
required to be made. When the amount of interest due on such a claim is
less [then] THAN two dollars, [and] AN insurer or organization or corpo-
ration shall not be required to pay interest on such claim.
[(d)] (2) EXCEPT AS PROVIDED IN PARAGRAPH FOUR OF THIS SUBSECTION, IN
A CASE WHERE AN INSURER, ORGANIZATION OR CORPORATION FAILS TO PAY THE
INTEREST AMOUNT SPECIFIED IN THIS SUBSECTION WITH THE AMOUNT OF THE
CLAIM OR HEALTH CARE PAYMENT, THE SUPERINTENDENT SHALL IMPOSE THE MAXI-
MUM PENALTY PROVIDED IN THIS CHAPTER.
(3) PURSUANT TO PARAGRAPH (G) OF SUBDIVISION FOUR OF SECTION
TWENTY-EIGHT HUNDRED SEVEN-E OF THE PUBLIC HEALTH LAW, FOR EACH CLAIM OR
BILL FOR HEALTH CARE SERVICES FOR WHICH AN INSURER, ORGANIZATION OR
CORPORATION CANNOT ACCEPT ELECTRONIC TRANSMISSION FROM A HEALTH CARE
PROVIDER, THE INSURER, ORGANIZATION OR CORPORATION SHALL BE OBLIGATED TO
PAY AN ADDITIONAL AMOUNT OF INTEREST EQUAL TO TWO PERCENT OF THE AMOUNT
OF THE CLAIM.
(4) IF, AFTER INVESTIGATION, THE SUPERINTENDENT FINDS THAT AN INSURER,
ORGANIZATION, OR CORPORATION HAS PROCESSED NINETY-EIGHT PER CENTUM OF
CLAIMS RECEIVED IN A GIVEN TIME PERIOD IN COMPLIANCE WITH THIS SECTION,
THEN ANY REMAINING CLAIMS NOT PROCESSED IN COMPLIANCE WITH THIS SECTION
BUT WHICH WERE PAID WITHIN SIXTY DAYS OF SUBMISSION AND WITH THE APPRO-
PRIATE INTEREST PAYMENT FOR LATE CLAIMS SHALL NOT CONSTITUTE VIOLATIONS
OF THIS SECTION, SO LONG AS SUCH CLAIMS OWED TO AN INDIVIDUAL HEALTH
CARE PROVIDER, IN THE AGGREGATE, DO NOT EXCEED FIVE PERCENT OF THE
ACCOUNTS RECEIVABLE OWED BY THAT INSURER, ORGANIZATION OR CORPORATION TO
THAT HEALTH CARE PROVIDER FOR SUCH PERIOD.
(F) For the purposes of this section:
(1) "policyholder" shall mean a person covered under such policy or a
representative designated by such person; and
(2) "health care provider" shall mean an entity licensed or certified
pursuant to article twenty-eight, thirty-six or forty of the public
A. 793 14
health law, a facility licensed pursuant to article nineteen, FORMER
ARTICLE twenty-three or ARTICLE thirty-one of the mental hygiene law, a
health care professional licensed, registered or certified pursuant to
title eight of the education law, a dispenser or provider of pharmaceu-
tical products, services or durable medical equipment, or a represen-
tative designated by such entity or person.
[(e)] (G) IN A CASE WHERE (A) MORE THAN FIVE PERCENT OF THE ACCOUNTS
RECEIVABLE BALANCE DUE TO A HEALTH CARE PROVIDER FROM AN INSURER, ORGAN-
IZATION OR CORPORATION IS WITHHELD BECAUSE THE OBLIGATION TO PAY IS NOT
REASONABLY CLEAR PURSUANT TO SUBSECTION (B) OF THIS SECTION, OR (B) AN
INSURER, ORGANIZATION OR CORPORATION REQUESTS A PATIENT'S MEDICAL
RECORDS PURSUANT TO PARAGRAPH TWO OF SUBSECTION (B) OF THIS SECTION FOR
MORE THAN FIVE PERCENT OF CLAIMS SUBMITTED BY A HEALTH CARE PROVIDER,
THERE SHALL BE A PRESUMPTION THAT PAYMENT HAS NOT BEEN WITHHELD BECAUSE
OF A GOOD FAITH DISPUTE AND THE SUPERINTENDENT SHALL INVESTIGATE THE
PAYMENT PRACTICES OF THE INSURER, ORGANIZATION OR CORPORATION. IN ADDI-
TION, THE SUPERINTENDENT SHALL INVESTIGATE THE PAYMENT PRACTICES OF THE
INSURER, ORGANIZATION OR CORPORATION IN ANY INSTANCE WHERE HE OR SHE HAS
REASON TO BELIEVE THAT THE INSURER, ORGANIZATION OR CORPORATION HAS NOT
COMPLIED WITH THE PROVISIONS OF THIS SECTION. IN DETERMINING WHETHER
MORE THAN FIVE PERCENT OF THE ACCOUNTS RECEIVABLE BALANCE DUE TO A
HEALTH CARE PROVIDER FROM AN INSURER, ORGANIZATION OR CORPORATION IS
WITHHELD OR WHETHER MEDICAL RECORDS ARE REQUESTED FOR MORE THAN FIVE
PERCENT OF THE CLAIMS SUBMITTED BY A HEALTH CARE PROVIDER, THE SUPER-
INTENDENT SHALL DISREGARD CLAIMS FOR REIMBURSEMENT OF EMERGENCY CARE
RENDERED BY A HEALTH CARE PROVIDER THAT DOES NOT PARTICIPATE IN THE
NETWORK OF THE INSURER, ORGANIZATION OR CORPORATION RECEIVING THE CLAIM.
(H) Nothing in this section shall in any way be deemed to impair any
right available to the state to adjust the timing of its payments for
medical assistance pursuant to title eleven of article five of the
social services law, or for child health insurance plan benefits pursu-
ant to title [one-a] ONE-A of article twenty-five of the public health
law or otherwise be deemed to require adjustment of payments by the
state for such medical assistance or child health insurance.
[(f)] (I) In any action brought by the superintendent pursuant to this
section or article twenty-four of this chapter relating to this section
regarding payments for medical assistance pursuant to title eleven of
article five of the social services law, child health insurance plan
benefits pursuant to title [one-a] ONE-A of article twenty-five of the
public health law, benefits under the voucher insurance program pursuant
to section one thousand one hundred twenty-one of this chapter, and
benefits under the New York state small business health insurance part-
nership program pursuant to article nine-A of the public health law, it
shall be a mitigating factor that the insurer, corporation or organiza-
tion is owed any premium amounts, premium adjustments, stop-loss recov-
eries or other payments from the state or one of its fiscal interme-
diaries under any such program.
S 26. This act shall take effect immediately, except that sections one
through ten and sections fifteen through twenty-five of this act shall
take effect on the first of January next succeeding the date on which it
shall have become a law and sections eleven, twelve, thirteen and four-
teen of this act shall take effect on the sixtieth day after it shall
have become a law; provided, however, that the amendments to section
364-j of the social services law made by section four of this act shall
not affect the repeal of such section and shall be deemed repealed ther-
ewith; provided, further, that if section 7 of chapter 388 of the laws
A. 793 15
of 2008 shall not have taken effect on or before the first of January
next succeeding the date on which this act shall have become a law, the
amendments to paragraph 6 of subsection (a) of section 2601 of the
insurance law made by section twenty-four of this act shall take effect
on the same date and in the same manner as such chapter of the laws of
2008 takes effect. Effective immediately, the addition, amendment
and/or repeal of any rule or regulation or other administrative action
necessary for the implementation of this act on its effective date are
authorized and directed to be made and completed on or before such
effective date.