Senate Bill S4509

2011-2012 Legislative Session

Regulates the scope, manner and performance of review of claims by utilization review agents

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Archive: Last Bill Status - In Senate Committee Health 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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Date of Action	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 04, 2012	referred to health
Apr 08, 2011	referred to health

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2011-S4509 (ACTIVE) - Details

See Assembly Version of this Bill:: A659
Current Committee:: Senate Health
Law Section:: Public Health Law
Laws Affected:: Amd §§4902, 4903, 4904, 4905, & 4910, Pub Health L; amd §§4902, 4903, 4904, 4905 & 4910, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: A792
2013-2014: A2691

2011-S4509 (ACTIVE) - Summary

Regulates the scope, manner and performance of review of claims by utilization review agents; provides that denial of coverage for emergency services is not based solely on final diagnosis.

2011-S4509 (ACTIVE) - Sponsor Memo

                                BILL NUMBER:S4509

TITLE OF BILL:
An act
to amend the public health law and the insurance law, in relation to
approvals by a utilization review agent

PURPOSE:
To improve managed care market conduct and to prohibit
inappropriate health insurance practices

SUMMARY OF PROVISIONS:
Sections 1 and 2 enhance the utilization review
law;

Sections 3 and 4 ensure payment for authorized medical care;

Sections 5-10 protect providers' rights under the external appeals law;

Sections 11 is the effective date.

JUSTIFICATION:
New York State law establishes timeframes in which
utilization review agents must make adverse determinations. However,
the law needs to be enhanced to protect consumers and providers. The
way the current statute is written, the failure of a health plan to

provide timely decisions about medical necessity is not penalized. In
fact, that failure accrues to the benefit of the plan as a denial.
The failure to make a utilization review decision within the stated
time should be deemed an approved claim and not an adverse
determination.

The current External Appeal Program within the NYS Insurance
Department (SID) is dysfunctional resulting in an ineffectual and
underused consumer protection statute. Currently, providers (who are
in the strongest position to advocate on behalf of the patient for
necessary medical care) are frequently unable to appeal adverse
determinations regarding medical necessity. This is mainly because
SID has not recognized the two possible methods for a provider
appeal. Specifically, SID has refused to honor designations by
patients, and SID deems retrospective adverse determinations by plans
to be concurrent, which therefore disqualifies the provider's
external appeal review. The administrative shortcomings of the
External Appeal Law must be corrected so that its use can be
maximized. Providers must have a clear right to appeal adverse
determinations particularly since providers are currently prohibited
from balance billing patients for covered services that are denied by
the plan.

Administrative Burden for Emergency Department (ED) visits commercial
health plans should be required to consider certain common sense
factors
in applying the prudent layperson standard when determining whether
the medical care provided was for emergency medical services. A
utilization review agent should be required to consider the time of
day and the day of the week the patient presented to the emergency


department, in addition to the presenting symptoms, when reviewing
coverage of emergency services to treat an emergency medical condition.

LEGISLATIVE HISTORY:
2007-08: A.8321-B - Passed Assembly
2009-10: A.792-A - Passed Assembly.

FISCAL IMPLICATIONS:
None.

EFFECTIVE DATE:
January 1, next succeeding the date on which it shall
have become law.

2011-S4509 (ACTIVE) - Bill Text download pdf

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

                                  4509

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                              April 8, 2011
                               ___________

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

AN ACT to amend the public health law and the insurance law, in relation
  to approvals by a utilization review agent

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

  Section  1.  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 nor shall
reimbursement for such  services  be  denied  on  retrospective  review;
provided,  however, that such services are medically necessary to stabi-
lize or treat an emergency condition.  IN REVIEWING A DENIAL FOR  COVER-
AGE  OF  EMERGENCY SERVICES TO TREAT AN EMERGENCY MEDICAL CONDITION, THE
UTILIZATION REVIEW AGENT SHALL TAKE THE FOLLOWING FACTORS INTO CONSIDER-
ATION:
  (1) THE TIME OF DAY AND DAY OF THE WEEK THE CARE WAS PROVIDED;
  (2) THE PRESENTING SYMPTOMS, INCLUDING  BUT  NOT  LIMITED  TO,  SEVERE
PAIN,  TO  ENSURE  THAT THE DECISION TO DENY REIMBURSEMENT FOR EMERGENCY
SERVICE IS NOT MADE SOLELY ON THE BASIS OF THE FINAL DIAGNOSIS.
  S 2. Subdivision 7 of section 4903 of the public health law, as  added
by chapter 586 of the laws of 1998, is amended to read as follows:
  7.  Failure  by  the  utilization review agent to make a determination
within the time periods prescribed in this section shall be deemed to be
an [adverse determination subject to appeal pursuant  to  section  forty
nine hundred four of this title] APPROVAL.
  S  3. Subdivision 1 of section 4904 of the public health law, as added
by chapter 705 of the laws of 1996, is amended to read as follows:
  1. An enrollee, the  enrollee's  designee  and[,  in  connection  with
retrospective adverse determinations,] an enrollee's health care provid-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD02281-02-1

S. 4509                             2

er, may appeal an adverse determination rendered by a utilization review
agent.
  S  4.  The  opening  paragraph of subdivision 5 of section 4905 of the
public health law is designated paragraph (a) and a new paragraph (b) is
added to read as follows:
  (B) 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  SPECIFIC  WEBPAGE  OF  THE
INSURER'S  WEBSITE  TO WHICH THE PROVIDER HAS BEEN DIRECTED AND TO WHICH
THE PROVIDER HAS BEEN GIVEN ACCESS SO THAT THE PROVIDER MAY  IMMEDIATELY
PRINT AND RETAIN A HARD COPY.
  S  5.  The  opening  paragraph of subdivision 2 of section 4910 of the
public health law, as amended by chapter 237 of the  laws  of  2009,  is
amended to read as follows:
  An  enrollee, the enrollee's designee and[, in connection with concur-
rent and retrospective adverse  determinations,]  an  enrollee's  health
care provider, shall have the right to request an external appeal when:
  S  6.  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 nor shall
reimbursement for such  services  be  denied  on  retrospective  review;
provided,  however, that such services are medically necessary to stabi-
lize or treat an emergency condition.  IN REVIEWING A DENIAL FOR  COVER-
AGE  OF  EMERGENCY SERVICES TO TREAT AN EMERGENCY MEDICAL CONDITION, THE
UTILIZATION REVIEW AGENT SHALL TAKE THE FOLLOWING FACTORS INTO CONSIDER-
ATION:
  (I) THE TIME OF DAY AND DAY OF THE WEEK THE CARE WAS PROVIDED;
  (II) THE PRESENTING SYMPTOMS, INCLUDING BUT  NOT  LIMITED  TO,  SEVERE
PAIN,  TO  ENSURE  THAT THE DECISION TO DENY REIMBURSEMENT FOR EMERGENCY
SERVICE IS NOT MADE SOLELY ON THE BASIS OF THE FINAL DIAGNOSIS.
  S 7. Subsection (g) of section 4903 of the insurance law, as added  by
chapter 586 of the laws of 1998, is amended to read as follows:
  (g)  Failure  by  the utilization review agent to make a determination
within the time periods prescribed in this section shall be deemed to be
an [adverse determination subject to appeal  pursuant  to  section  four
thousand nine hundred four of this title] APPROVAL.
  S  8. Subsection (a) of section 4904 of the insurance law, as added by
chapter 705 of the laws of 1996, is amended to read as follows:
  (a) An insured, the insured's designee and[, in connection with retro-
spective adverse determinations,] an insured's health care provider, may
appeal an adverse determination rendered by a utilization review agent.
  S 9. The opening paragraph of subsection (e) of section  4905  of  the
insurance  law  is designated paragraph 1 and a new paragraph 2 is added
to read as follows:
  (2) 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:

S. 4509                             3

  (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 SPECIFIC WEBPAGE OF THE
INSURER'S WEBSITE TO WHICH THE PROVIDER HAS BEEN DIRECTED AND  TO  WHICH
THE  PROVIDER HAS BEEN GIVEN ACCESS SO THAT THE PROVIDER MAY IMMEDIATELY
PRINT AND RETAIN A HARD COPY.
  S 10. The opening paragraph of subsection (b) of section 4910  of  the
insurance law, as amended by chapter 237 of the laws of 2009, is amended
to read as follows:
  An insured, the insured's designee and[, in connection with concurrent
and  retrospective  adverse  determinations,]  an  insured's health care
provider, shall have the right to request an external appeal when:
  S 11.  This act shall take effect on January first next succeeding the
date on which it shall have become a law, and shall apply to  all  poli-
cies  and contracts issued, renewed, modified, altered or amended on and
after such effective date.

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Senate Bill S4509

Sponsored By

Archive: Last Bill Status - In Senate Committee Health Committee

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co-Sponsors

2011-S4509 (ACTIVE) - Details

2011-S4509 (ACTIVE) - Summary

2011-S4509 (ACTIVE) - Sponsor Memo

2011-S4509 (ACTIVE) - Bill Text download pdf

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Sponsored By

Kemp Hannon

Archive: Last Bill Status - In Senate Committee Health Committee

Actions

co-Sponsors

Tony Avella

John A. DeFrancisco

Liz Krueger

William Larkin

2011-S4509 (ACTIVE) - Details

2011-S4509 (ACTIVE) - Summary

2011-S4509 (ACTIVE) - Sponsor Memo

2011-S4509 (ACTIVE) - Bill Text download pdf

Comments