Senate Bill S4453A

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

                                 4453--A

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                              April 6, 2011
                               ___________

Introduced  by  Sens. DeFRANCISCO, LARKIN, RANZENHOFER -- read twice and
  ordered printed, and when printed to be committed to the Committee  on
  Insurance  --  recommitted to the Committee on Insurance in accordance
  with Senate Rule 6, sec. 8  --  committee  discharged,  bill  amended,
  ordered reprinted as amended and recommitted to said committee

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

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

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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD08992-02-2

              

S. 4453--A                          2

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

S. 4453--A                          3

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