NY State Senate Bill 2009-S7472

Senate Bill S7472

2009-2010 Legislative Session

Requires insurance companies to supply providers with written confirmation of oral approval for services upon an insured

download bill text pdf

Archive: Last Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Actions

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Apr 14, 2010	referred to insurance

2009-S7472 (ACTIVE) - Details

Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §4905, Ins L; amd §4905, Pub Health L

2009-S7472 (ACTIVE) - Summary

Requires insurance companies to supply providers with written confirmation of oral approval for services upon an insured.

2009-S7472 (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S7472

 TITLE OF BILL :

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


 PURPOSE OR GENERAL IDEA OF THE BILL :

This bill requires insurance companies to supply providers with
written confirmation of oral approval for services upon an insured,
and maintains that such authorization cannot be retroactively denied
without evidence of misrepresentation on the part of the provider or
the enrollee.

 SUMMARY OF SPECIFIC PROVISIONS :

Section one amends subsection (e) of section 4905 of the insurance
law, as added by chapter 705 of the laws of 1996 to require a
utilization review agent to immediately corroborate a verbal approval
for medical services with written confirmation of the approval. Such
written confirmation may be presented through electronic mail,
delivered to an address specified by the provider, facsimile
transmission to a number specified by the provider, or through a
posting on a website accessible to the provider so that the provider

may immediately print and retain a hard copy. In the absence of
misrepresentation by the provider or the covered patient, the written
approval shall be considered prima facie evidence that the services
performed by the provider were covered services considered medically
necessary. The performance of these services shall not be denied in
light of written approval, nor shall timely reimbursement for such
services be denied or limited. In cases where 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 basis if such services
are determined not to be medically necessary.

Section two amends subdivision (5) of section 4905 of the public
health law, as added by chapter 705 of the laws of 1996 to require a
utilization review agent to immediately corroborate a verbal approval
for medical services with written confirmation of the approval. Such
written confirmation may be presented through electronic mail,
delivered to an address specified by the provider, facsimile
transmission to a number specified by the provider, or through a
posting on a website accessible to the provider so that the provider
may immediately print and retain a hard copy. In the absence of
misrepresentation by the provider or the covered patient, the written
approval shall be considered prima facie evidence that the services
performed by the provider were covered services considered medically
necessary. The performance of these services shall not be denied in
light of written approval, nor shall timely reimbursement for such
services be denied or limited. In cases where 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 basis if such services
are determined not to be medically necessary.

Section three states that this act shall take effect on the sixtieth
day after it shall have become law.

 JUSTIFICATION :
Insurance companies often extend verbal approvals of requests for
pre-certification and authorization by health care providers, and then
thereafter deny the services once they have been completed. This
policy forces patients, physicians and hospitals to absorb costs for
services the insurer approved. Verbal approvals should be followed by
a hard copy, sent via e-mail or fax, or posted on the insurer's
website, so that the health care providers and/or hospitals can print
the approval, and that documentation should be prima facie evidence
that the services were indeed covered by the carrier absent a
misrepresentation by the provider or the patient.

 PRIOR LEGISLATIVE HISTORY :
2009: A.3163 Referred to Insurance;
2007-2008: A.5207A/S.5316A Referred to Insurance

 FISCAL IMPLICATIONS :
None.

 EFFECTIVE DATE :
This act shall take effect on the sixtieth (60) day after it shall
have become law.

2009-S7472 (ACTIVE) - Bill Text download pdf

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

                                  7472

                            I N  S E N A T E

                             April 14, 2010
                               ___________

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

AN ACT to amend the insurance law and the public health law, in relation
  to 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
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

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

S. 7472                             2

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.

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