senate Bill S4970B

2013-2014 Legislative Session

Requires health care plans and insurers to provide expedited review of applications of health care professionals who are joining a group practice

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Archive: Last Bill Status - In Committee


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor

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Actions

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
May 06, 2014 print number 4970b
amend and recommit to health
Feb 21, 2014 print number 4970a
amend and recommit to health
Jan 08, 2014 referred to health
May 02, 2013 referred to health

Bill Amendments

Original
A
B (Active)
Original
A
B (Active)

S4970 - Bill Details

See Assembly Version of this Bill:
A6426B
Current Committee:
Law Section:
Public Health Law
Laws Affected:
Amd §4406-d, Pub Health L; amd §4803, Ins L

S4970 - Bill Texts

view summary

Requires health care plans and insurers to provide expedited review of applications of health care professionals who are joining a group practice and grant provisional credentials to such professionals; provides that health care professionals who have received credentials and change the address of or add locations to the practice need only notify the health care plan or insurer of such change or addition.

view sponsor memo
BILL NUMBER:S4970

TITLE OF BILL: An act to amend the public health law and the
insurance law, in relation to requiring health care plans and insurers
to provide expedited review of applications of health care
professionals who are joining a group practice and grant provisional
credentials to such professionals

PURPOSE:

Requires health care plans and insurers to provide expedited review of
applications of health care professionals who are joining a group
practice.

SUMMARY OF SPECIFIC PROVISIONS:

Section 1 of the bill amends the section 4406-d of the public health
law.

Section 2 amends section 4803 of the insurance law.

Section 3 establishes the effective date.

JUSTIFICATION:

Currently there is no requirement or incentive for insurance companies
to facilitate the timely processing of enrollment applications from
participating primary care physician groups for individual providers
joining such a group requesting to join the panel. A physician group
is defined as a group of one or more physicians which either has a
group contract with the insurer, but still may still require
individual enrollment, or a group of physicians of which at least one
is a participating provider in the plan. These delays make it
virtually impossible for the incoming physician to see patients until
60, 90 or even 120 days after the initial application, even while
still needing to be a functioning part of the group.

Insurance companies already have such expedited measures for
specialists. There are no existing mechanisms for primary care
physicians, which can cause up to 6 months of delays in credentialing.
Lost revenue, lost physician productivity and untenable working
schedules for physicians while waiting for insurance approval make
these delays unreasonable. The pressure placed upon physicians groups
to bill visits by non-part providers in their group through their part
providers is strong, and it is not good sound accounting practice in
the long run for either the insurance company or the provider group.
Therefore, temporary credentials, expedited enrollment, and expedited
change in address from previous practice will all help to increase
ease of patient enrollment into the group practice, thereby easing
enrollment into the insurance plan as well. Since this is already
being done for specialist practices, physician groups should have the
same opportunity. Time and money are saved by the insurance companies
from long, redundant enrollment practices.

LEGISLATIVE HISTORY:

New bill.


FISCAL IMPLICATIONS:

None.

EFFECTIVE DATE:

This act shall take effect on the one hundred eightieth day after it
shall have become a law.

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

                                  4970

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                               May 2, 2013
                               ___________

Introduced  by  Sen.  LANZA  -- 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 requiring health care  plans  and  insurers  to  provide  expedited
  review  of applications of health care professionals who are joining a
  group practice and grant provisional credentials to such professionals

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

  Section  1.  Subdivision 1 of section 4406-d of the public health law,
as amended by chapter 237 of the laws of 2009, is  amended  to  read  as
follows:
  1.  (a)  A  health  care  plan shall, upon request, make available and
disclose to health care professionals written application procedures and
minimum qualification requirements which a health care professional must
meet in order to be considered by the health care plan. The  plan  shall
consult with appropriately qualified health care professionals in devel-
oping  its qualification requirements. A health care plan shall complete
review of the health care professional's application to  participate  in
the  in-network  portion  of  the  health care plan's network and shall,
within ninety days of receiving a health care  professional's  completed
application to participate in the health care plan's network, notify the
health  care  professional as to: (i) whether he or she is credentialed;
or (ii) whether additional time is necessary to make a determination  in
spite  of the health care plan's best efforts or because of a failure of
a third party to provide  necessary  documentation,  or  non-routine  or
unusual  circumstances  require  additional  time  for  review.  In such
instances where additional time is necessary because of a lack of neces-
sary documentation, a health plan shall make every effort to obtain such
information as soon as possible. PROVIDED, HOWEVER, THAT IF  THE  APPLI-
CANT  IS  A  HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE OF
HEALTH CARE PROFESSIONALS, AT LEAST ONE  OF  WHOM  PARTICIPATES  IN  THE

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD09628-01-3

S. 4970                             2

IN-NETWORK  PORTION  OF A HEALTH CARE PLAN'S NETWORK, A HEALTH CARE PLAN
SHALL, WITHIN THIRTY DAYS OF RECEIVING SUCH A HEALTH CARE PROFESSIONAL'S
COMPLETE APPLICATION TO PARTICIPATE IN THE HEALTH CARE  PLAN'S  NETWORK,
INCLUDING  SUBMISSION  OF ALL NECESSARY DOCUMENTATION FROM THE APPLICANT
AND THIRD PARTIES, COMPLETE REVIEW AND NOTIFY THE  HEALTH  CARE  PROFES-
SIONAL AS TO WHETHER HE OR SHE IS CREDENTIALED.
  (b)  If  the  completed  application  of  a newly-licensed health care
professional or a health care professional who has recently relocated to
this state from another state and has not previously practiced  in  this
state,  who  joins a group practice of health care professionals each of
whom participates in the in-network portion  of  a  health  care  plan's
network, is neither approved nor declined within ninety days pursuant to
paragraph (a) of this subdivision, the health care professional shall be
deemed  "provisionally  credentialed" and may participate in the in-net-
work portion of the health care plan's network[; provided, however, that
a provisionally credentialed physician  may  not  be  designated  as  an
enrollee's  primary  care physician until such time as the physician has
been fully credentialed]. The network participation for  a  HEALTH  CARE
PROFESSIONAL  DEEMED  provisionally  credentialed  [health  care profes-
sional] PURSUANT TO THIS PARAGRAPH shall begin on the day following  the
ninetieth  day  of  receipt  of the completed application and shall last
until the final credentialing determination is made by the  health  care
plan. [A health care professional shall only be eligible for provisional
credentialing  if  the group practice of health care professionals noti-
fies the health care plan in writing that, should the application  ulti-
mately  be  denied,  the health care professional or the group practice:
(i) shall refund any payments made by the health care plan  for  in-net-
work  services  provided  by  the provisionally credentialed health care
professional that exceed any out-of-network benefits payable  under  the
enrollee's  contract  with  the  health care plan; and (ii)] IT SHALL BE
UNDERSTOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT WILL
BE APPROVED BUT HELD BY THE  HEALTH  CARE  PLAN  UNTIL  FINAL  APPROVAL;
PROVIDED,  HOWEVER,  THAT  IF REIMBURSEMENT IS DENIED, THE PROVISIONALLY
CREDENTIALED PROVIDER shall not pursue reimbursement from the  enrollee,
except  to  collect the copayment that otherwise would have been payable
had the enrollee received  services  from  a  health  care  professional
participating in the in-network portion of a health care plan's network.
Interest  and  penalties  pursuant to section three thousand two hundred
twenty-four-a of the insurance law shall not be assessed  based  on  the
denial  of  a  claim  submitted  during  the period when the health care
professional was provisionally  credentialed;  provided,  however,  that
nothing herein shall prevent a health care plan from paying a claim from
a  health  care  professional  who  is  provisionally  credentialed upon
submission of such claim. A health  care  plan  shall  not  deny,  after
appeal,  a  claim  for services provided by a provisionally credentialed
health care professional solely on the ground that  the  claim  was  not
timely filed.
  (C)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH  CARE  PROFESSIONALS,  AT  LEAST  ONE  OF  WHOM
PARTICIPATES  IN THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK,
UPON HIS OR HER SUBMISSION OF A COMPLETE APPLICATION TO  PARTICIPATE  IN
THE  HEALTH  CARE  PLAN'S NETWORK, INCLUDING SUBMISSION OF ALL NECESSARY
DOCUMENTATION FROM THE APPLICANT AND THIRD PARTIES, HE OR SHE  SHALL  BE
DEEMED  "PROVISIONALLY  CREDENTIALED" AND MAY PARTICIPATE IN THE IN-NET-
WORK PORTION OF THE HEALTH CARE  PLAN'S  NETWORK.  THE  NETWORK  PARTIC-
IPATION FOR A HEALTH CARE PROFESSIONAL DEEMED PROVISIONALLY CREDENTIALED

S. 4970                             3

PURSUANT TO THIS PARAGRAPH SHALL BEGIN ON THE DAY FOLLOWING NOTIFICATION
BY  THE HEALTH CARE PLAN THAT THE COMPLETED APPLICATION WAS RECEIVED AND
SHALL LAST UNTIL THE FINAL CREDENTIALING DETERMINATION IS  MADE  BY  THE
HEALTH CARE PLAN.
  (D)  IF  A  HEALTH  CARE PROFESSIONAL IS DEEMED "PROVISIONALLY CREDEN-
TIALED" PURSUANT TO PARAGRAPH (B) OR (C) OF THIS SUBDIVISION, HE OR  SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME  AS  THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL BE UNDER-
STOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT  WILL  BE
APPROVED  BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL APPROVAL;
PROVIDED, HOWEVER, THAT IF REIMBURSEMENT IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER SHALL NOT PURSUE REIMBURSEMENT FROM THE ENROLLEE,
EXCEPT TO COLLECT THE COPAYMENT THAT OTHERWISE WOULD HAVE  BEEN  PAYABLE
HAD  THE  ENROLLEE  RECEIVED  SERVICES  FROM  A HEALTH CARE PROFESSIONAL
PARTICIPATING IN THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK.
INTEREST AND PENALTIES PURSUANT TO SECTION THREE  THOUSAND  TWO  HUNDRED
TWENTY-FOUR-A  OF  THE  INSURANCE LAW SHALL NOT BE ASSESSED BASED ON THE
DENIAL OF A CLAIM SUBMITTED DURING  THE  PERIOD  WHEN  THE  HEALTH  CARE
PROFESSIONAL  WAS  PROVISIONALLY  CREDENTIALED;  PROVIDED, HOWEVER, THAT
NOTHING HEREIN SHALL PREVENT A HEALTH CARE PLAN FROM PAYING A CLAIM FROM
A HEALTH  CARE  PROFESSIONAL  WHO  IS  PROVISIONALLY  CREDENTIALED  UPON
SUBMISSION  OF  SUCH  CLAIM.  A  HEALTH  CARE PLAN SHALL NOT DENY, AFTER
APPEAL, A CLAIM FOR SERVICES PROVIDED BY  A  PROVISIONALLY  CREDENTIALED
HEALTH  CARE  PROFESSIONAL  SOLELY  ON THE GROUND THAT THE CLAIM WAS NOT
TIMELY FILED.
  (E) IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED  BY  A  HEALTH
CARE PLAN PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR
TO EXPIRATION OR TERMINATION OF HIS OR HER CONTRACT WITH THE HEALTH CARE
PLAN,  THE  HEALTH  CARE  PROFESSIONAL OR THE GROUP PRACTICE CHANGES THE
ADDRESS OF OR ADDS AN ADDITIONAL LOCATION TO THE  PRACTICE,  HE  OR  SHE
SHALL NOT BE REQUIRED TO REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED
TO FILE NOTICE OF SUCH CHANGE OR ADDITION WITH THE HEALTH CARE PLAN.
  S  2.  Subsection (a) of section 4803 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (a) (1) An insurer which offers a managed  care  product  shall,  upon
request,  make available and disclose to health care professionals writ-
ten application procedures and minimum qualification requirements  which
a  health  care  professional must meet in order to be considered by the
insurer for participation in the  in-network  benefits  portion  of  the
insurer's  network  for  the  managed  care  product.  The insurer shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits portion of the insurer's network for the managed care  product.
An  insurer  shall  complete  review  of  the health care professional's
application to participate in the in-network portion  of  the  insurer's
network  and,  within  ninety  days  of  receiving a health care profes-
sional's completed application to participate in the insurer's  network,
will notify the health care professional as to: (A) whether he or she is
credentialed;  or  (B)  whether  additional  time is necessary to make a
determination in spite of the insurer's best efforts  or  because  of  a
failure  of  a  third  party to provide necessary documentation, or non-
routine or unusual circumstances require additional time for review.  In
such instances where additional time is necessary because of a  lack  of
necessary  documentation,  an  insurer shall make every effort to obtain
such information as soon as possible. PROVIDED,  HOWEVER,  THAT  IF  THE
APPLICANT  IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE

S. 4970                             4

OF HEALTH CARE PROFESSIONALS, AT LEAST ONE OF WHOM PARTICIPATES  IN  THE
IN-NETWORK  PORTION  OF  AN  INSURER'S NETWORK, AN INSURER SHALL, WITHIN
THIRTY DAYS OF RECEIVING SUCH  A  HEALTH  CARE  PROFESSIONAL'S  COMPLETE
APPLICATION TO PARTICIPATE IN AN INSURER'S NETWORK, INCLUDING SUBMISSION
OF  ALL  NECESSARY  DOCUMENTATION  FROM THE APPLICANT AND THIRD PARTIES,
COMPLETE REVIEW AND NOTIFY THE HEALTH CARE PROFESSIONAL AS TO WHETHER HE
OR SHE IS CREDENTIALED.
  (2) If the completed  application  of  a  newly-licensed  health  care
professional or a health care professional who has recently relocated to
this  state  from another state and has not previously practiced in this
state, who joins a group practice of health care professionals  each  of
whom  participates in the in-network portion of an insurer's network, is
neither approved nor declined within ninety days pursuant  to  paragraph
one  of  this  subsection, such health care professional shall be deemed
"provisionally credentialed"  and  may  participate  in  the  in-network
portion  of  an  insurer's  network[;  provided,  however, that a provi-
sionally credentialed physician may not be designated  as  an  insured's
primary  care  physician until such time as the physician has been fully
credentialed]. The network participation for a HEALTH CARE  PROFESSIONAL
DEEMED provisionally credentialed [health care professional] PURSUANT TO
THIS  PARAGRAPH  shall  begin  on the day following the ninetieth day of
receipt of the completed application and  shall  last  until  the  final
credentialing  determination  is  made  by  the  insurer. [A health care
professional shall only be eligible for provisional credentialing if the
group practice of health care  professionals  notifies  the  insurer  in
writing  that,  should  the application ultimately be denied, the health
care professional or the group practice: (A) shall refund  any  payments
made  by  the  insurer  for  in-network  services provided by the provi-
sionally credentialed health care professional that exceed  any  out-of-
network  benefits payable under the insured's contract with the insurer;
and (B)] IT SHALL BE UNDERSTOOD THAT PROVISIONALLY CREDENTIALED  PROVID-
ERS'  REIMBURSEMENT  WILL  BE  APPROVED BUT HELD BY THE HEALTH CARE PLAN
UNTIL FINAL  APPROVAL;  PROVIDED,  HOWEVER,  THAT  IF  REIMBURSEMENT  IS
DENIED,   THE  PROVISIONALLY  CREDENTIALED  PROVIDER  shall  not  pursue
reimbursement from the insured, except to collect the copayment or coin-
surance that otherwise would have been payable had the insured  received
services from a health care professional participating in the in-network
portion  of  an  insurer's  network.  Interest and penalties pursuant to
section three thousand two hundred twenty-four-a of this  chapter  shall
not  be  assessed  based  on  the denial of a claim submitted during the
period when the health care professional was provisionally credentialed;
provided, however, that nothing herein shall  prevent  an  insurer  from
paying  a  claim  from  a  health care professional who is provisionally
credentialed upon submission of such claim. An insurer shall  not  deny,
after  appeal,  a claim for services provided by a provisionally creden-
tialed health care professional solely on the ground that the claim  was
not timely filed.
  (3)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH  CARE  PROFESSIONALS,  AT  LEAST  ONE  OF  WHOM
PARTICIPATES IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK, UPON HIS
OR HER SUBMISSION OF A COMPLETE APPLICATION TO PARTICIPATE IN THE INSUR-
ER'S  NETWORK,  INCLUDING SUBMISSION OF ALL NECESSARY DOCUMENTATION FROM
THE APPLICANT AND THIRD PARTIES, HE  OR  SHE  SHALL  BE  DEEMED  "PROVI-
SIONALLY  CREDENTIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF
THE INSURER'S NETWORK. THE  NETWORK  PARTICIPATION  FOR  A  HEALTH  CARE
PROFESSIONAL  DEEMED  PROVISIONALLY  CREDENTIALED PURSUANT TO THIS PARA-

S. 4970                             5

GRAPH SHALL BEGIN ON THE DAY FOLLOWING NOTIFICATION BY THE INSURER  THAT
THE  COMPLETED  APPLICATION  WAS RECEIVED AND SHALL LAST UNTIL THE FINAL
CREDENTIALING DETERMINATION IS MADE BY THE INSURER.
  (4)  IF  A  HEALTH  CARE PROFESSIONAL IS DEEMED "PROVISIONALLY CREDEN-
TIALED" PURSUANT TO PARAGRAPH TWO OR THREE OF THIS SUBSECTION, HE OR SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME AS THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL  BE  UNDER-
STOOD  THAT  PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT WILL BE
APPROVED BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL  APPROVAL;
PROVIDED,  HOWEVER,  THAT  IF REIMBURSEMENT IS DENIED, THE PROVISIONALLY
CREDENTIALED PROVIDER SHALL NOT PURSUE REIMBURSEMENT FROM  THE  INSURED,
EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
BEEN  PAYABLE  HAD  THE  INSURED  RECEIVED  SERVICES  FROM A HEALTH CARE
PROFESSIONAL PARTICIPATING IN THE IN-NETWORK  PORTION  OF  AN  INSURER'S
NETWORK.  INTEREST  AND PENALTIES PURSUANT TO SECTION THREE THOUSAND TWO
HUNDRED TWENTY-FOUR-A OF THIS CHAPTER SHALL NOT BE ASSESSED BASED ON THE
DENIAL OF A CLAIM SUBMITTED DURING  THE  PERIOD  WHEN  THE  HEALTH  CARE
PROFESSIONAL  WAS  PROVISIONALLY  CREDENTIALED;  PROVIDED, HOWEVER, THAT
NOTHING HEREIN SHALL PREVENT AN INSURER  FROM  PAYING  A  CLAIM  FROM  A
HEALTH   CARE   PROFESSIONAL  WHO  IS  PROVISIONALLY  CREDENTIALED  UPON
SUBMISSION OF SUCH CLAIM. AN INSURER SHALL NOT  DENY,  AFTER  APPEAL,  A
CLAIM  FOR SERVICES PROVIDED BY A PROVISIONALLY CREDENTIALED HEALTH CARE
PROFESSIONAL SOLELY ON THE GROUND THAT THE CLAIM WAS NOT TIMELY FILED.
  (5) IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY AN  INSURER
PURSUANT  TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR TO EXPI-
RATION OR TERMINATION OF HIS  OR  HER  CONTRACT  WITH  THE  INSURER  FOR
PARTICIPATION  IN  THE  IN-NETWORK  BENEFITS  PORTION  OF  THE INSURER'S
NETWORK FOR A MANAGED CARE PRODUCT, THE HEALTH CARE PROFESSIONAL OR  THE
GROUP  PRACTICE CHANGES THE ADDRESS OF OR ADDS AN ADDITIONAL LOCATION TO
THE PRACTICE, SUCH HEALTH CARE PROFESSIONAL SHALL  NOT  BE  REQUIRED  TO
REAPPLY  FOR  CERTIFICATION BUT SHALL BE REQUIRED TO FILE NOTICE OF SUCH
CHANGE OR ADDITION WITH THE INSURER.
  S 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

S4970A - Bill Details

See Assembly Version of this Bill:
A6426B
Current Committee:
Law Section:
Public Health Law
Laws Affected:
Amd §4406-d, Pub Health L; amd §4803, Ins L

S4970A - Bill Texts

view summary

Requires health care plans and insurers to provide expedited review of applications of health care professionals who are joining a group practice and grant provisional credentials to such professionals; provides that health care professionals who have received credentials and change the address of or add locations to the practice need only notify the health care plan or insurer of such change or addition.

view sponsor memo
BILL NUMBER:S4970A

TITLE OF BILL: An act to amend the public health law and the
insurance law, in relation to requiring health care plans and insurers
to provide expedited review of applications of health care
professionals who are joining a group practice and grant provisional
credentials to such professionals

PURPOSE OR GENERAL IDEA OF BILL:

Requires health care plans and insurers to provide expedited review of
applications of health care professionals who are joining a group
practice.

SUMMARY OF SPECIFIC PROVISIONS:

Section 1 of the bill amends the section 4406-d of the public health
law.

Section 2 amends section 4803 of the insurance law.

Section 3 establishes the effective date.

JUSTIFICATION:

Currently there is no requirement or incentive for insurance companies
to facilitate the timely processing of enrollment applications from
participating primary care physician groups for individual providers
joining such a group requesting to join the panel. A physician group
is defined as a group of one or more physicians which either has a
group contract with the insurer, but still may still require
individual enrollment, or a group of physicians of which at least one
is a participating provider in the plan. These delays make it
virtually impossible for the incoming physician to see patients until
60, 90 or even 120 days after the initial application, even while
still needing to be a functioning part of the group.

Insurance companies already have such expedited measures for
specialists. There are no existing mechanisms for primary care
physicians, which can cause up to 6 months of delays in credentialing.
Lost revenue, lost physician productivity and untenable working
schedules for physicians while waiting for insurance approval make
these delays unreasonable. The pressure placed upon physicians groups
to bill visits by non-part providers in their group through their part
providers is strong, and it is not good sound accounting practice in
the long run for either the insurance company or the provider group.
Therefore, temporary credentials, expedited enrollment, and expedited
change in address from previous practice will all help to increase
ease of patient enrollment into the group practice, thereby easing
enrollment into the insurance plan as well. Since this is already
being done for specialist practices, physician groups should have the
same opportunity: Time and money are saved by the insurance companies
from long, redundant enrollment practices.

PRIOR LEGISLATIVE HISTORY:

2013: A.6426 - Referred to Health;


S.4978 - Referred to Health.

FISCAL IMPLICATIONS:

None.

EFFECTIVE DATE:

This act shall take effect on the one hundred eightieth day after it
shall have become a law.

view full text
download pdf
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 4970--A

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                               May 2, 2013
                               ___________

Introduced  by  Sen.  LANZA  -- read twice and ordered printed, and when
  printed to be committed to the Committee on Health --  recommitted  to
  the  Committee  on  Health 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 public health law and the insurance law, in relation
  to  requiring  health  care  plans  and  insurers to provide expedited
  review of applications of health care professionals who are joining  a
  group practice and grant provisional credentials to such professionals

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

  Section 1.  Subdivision 1 of section 4406-d of the public health  law,
as  amended  by  chapter  237 of the laws of 2009, is amended to read as
follows:
  1. (a) A health care plan shall,  upon  request,  make  available  and
disclose to health care professionals written application procedures and
minimum qualification requirements which a health care professional must
meet  in  order to be considered by the health care plan. The plan shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements. A health care plan shall  complete
review  of  the health care professional's application to participate in
the in-network portion of the health  care  plan's  network  and  shall,
within  ninety  days of receiving a health care professional's completed
application to participate in the health care plan's network, notify the
health care professional as to: (i) whether he or she  is  credentialed;
or  (ii) whether additional time is necessary to make a determination in
spite of the health care plan's best efforts or because of a failure  of
a  third  party  to  provide  necessary documentation, or non-routine or
unusual circumstances  require  additional  time  for  review.  In  such
instances where additional time is necessary because of a lack of neces-
sary documentation, a health plan shall make every effort to obtain such

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD09628-03-4

S. 4970--A                          2

information  as  soon as possible. PROVIDED, HOWEVER, THAT IF THE APPLI-
CANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A  GROUP  PRACTICE  OF
HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACILITY OPERATING UNDER
ARTICLE TWENTY-EIGHT OR THIRTY-ONE OF THIS CHAPTER THAT IS A PARTICIPAT-
ING  PROVIDER  IN  THE HEALTH PLAN, AT LEAST ONE OF WHOM PARTICIPATES IN
THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK,  A  HEALTH  CARE
PLAN  SHALL,  WITHIN THIRTY DAYS OF RECEIVING SUCH A HEALTH CARE PROFES-
SIONAL'S COMPLETE APPLICATION TO PARTICIPATE IN THE HEALTH  CARE  PLAN'S
NETWORK,  INCLUDING  SUBMISSION  OF ALL NECESSARY DOCUMENTATION FROM THE
APPLICANT AND THIRD PARTIES, COMPLETE REVIEW AND NOTIFY THE HEALTH  CARE
PROFESSIONAL AS TO WHETHER HE OR SHE IS CREDENTIALED.
  (b)  If  the  completed  application  of  a newly-licensed health care
professional or a health care professional who has recently relocated to
this state from another state and has not previously practiced  in  this
state,  who  joins a group practice of health care professionals each of
whom participates in the in-network portion  of  a  health  care  plan's
network, is neither approved nor declined within ninety days pursuant to
paragraph (a) of this subdivision, the health care professional shall be
deemed  "provisionally  credentialed" and may participate in the in-net-
work portion of the health care plan's network[; provided, however, that
a provisionally credentialed physician  may  not  be  designated  as  an
enrollee's  primary  care physician until such time as the physician has
been fully credentialed]. The network participation for  a  HEALTH  CARE
PROFESSIONAL  DEEMED  provisionally  credentialed  [health  care profes-
sional] PURSUANT TO THIS PARAGRAPH shall begin on the day following  the
ninetieth  day  of  receipt  of the completed application and shall last
until the final credentialing determination is made by the  health  care
plan. [A health care professional shall only be eligible for provisional
credentialing  if  the group practice of health care professionals noti-
fies the health care plan in writing that, should the application  ulti-
mately  be  denied,  the health care professional or the group practice:
(i) shall refund any payments made by the health care plan  for  in-net-
work  services  provided  by  the provisionally credentialed health care
professional that exceed any out-of-network benefits payable  under  the
enrollee's  contract  with  the  health care plan; and (ii)] IT SHALL BE
UNDERSTOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT WILL
BE APPROVED BUT HELD BY THE  HEALTH  CARE  PLAN  UNTIL  FINAL  APPROVAL;
PROVIDED,  HOWEVER,  THAT  IF REIMBURSEMENT IS DENIED, THE PROVISIONALLY
CREDENTIALED PROVIDER shall not pursue reimbursement from the  enrollee,
except  to  collect the copayment that otherwise would have been payable
had the enrollee received  services  from  a  health  care  professional
participating in the in-network portion of a health care plan's network.
Interest  and  penalties  pursuant to section three thousand two hundred
twenty-four-a of the insurance law shall not be assessed  based  on  the
denial  of  a  claim  submitted  during  the period when the health care
professional was provisionally  credentialed;  provided,  however,  that
nothing herein shall prevent a health care plan from paying a claim from
a  health  care  professional  who  is  provisionally  credentialed upon
submission of such claim. A health  care  plan  shall  not  deny,  after
appeal,  a  claim  for services provided by a provisionally credentialed
health care professional solely on the ground that  the  claim  was  not
timely filed.
  (C)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY OPERATING UNDER ARTICLE TWENTY-EIGHT OR THIRTY-ONE OF  THIS  CHAPTER
THAT  IS  A  PARTICIPATING  PROVIDER IN THE HEALTH PLAN, AT LEAST ONE OF

S. 4970--A                          3

WHOM PARTICIPATES IN THE IN-NETWORK PORTION  OF  A  HEALTH  CARE  PLAN'S
NETWORK, UPON HIS OR HER SUBMISSION OF A COMPLETE APPLICATION TO PARTIC-
IPATE  IN  THE  HEALTH  CARE PLAN'S NETWORK, INCLUDING SUBMISSION OF ALL
NECESSARY  DOCUMENTATION FROM THE APPLICANT AND THIRD PARTIES, HE OR SHE
SHALL BE DEEMED "PROVISIONALLY CREDENTIALED" AND MAY PARTICIPATE IN  THE
IN-NETWORK  PORTION  OF  THE  HEALTH  CARE  PLAN'S  NETWORK. THE NETWORK
PARTICIPATION  FOR  A  HEALTH  CARE  PROFESSIONAL  DEEMED  PROVISIONALLY
CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN ON THE DAY FOLLOWING
NOTIFICATION  BY THE HEALTH CARE PLAN THAT THE COMPLETED APPLICATION WAS
RECEIVED AND SHALL LAST UNTIL THE FINAL CREDENTIALING  DETERMINATION  IS
MADE BY THE HEALTH CARE PLAN.
  (D)  IF  A  HEALTH  CARE PROFESSIONAL IS DEEMED "PROVISIONALLY CREDEN-
TIALED" PURSUANT TO PARAGRAPH (B) OR (C) OF THIS SUBDIVISION, HE OR  SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME  AS  THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL BE UNDER-
STOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT  WILL  BE
APPROVED  BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL APPROVAL;
PROVIDED, HOWEVER, THAT IF REIMBURSEMENT IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER SHALL NOT PURSUE REIMBURSEMENT FROM THE ENROLLEE,
EXCEPT TO COLLECT THE COPAYMENT THAT OTHERWISE WOULD HAVE  BEEN  PAYABLE
HAD  THE  ENROLLEE  RECEIVED  SERVICES  FROM  A HEALTH CARE PROFESSIONAL
PARTICIPATING IN THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK.
INTEREST AND PENALTIES PURSUANT TO SECTION THREE  THOUSAND  TWO  HUNDRED
TWENTY-FOUR-A  OF  THE  INSURANCE LAW SHALL NOT BE ASSESSED BASED ON THE
DENIAL OF A CLAIM SUBMITTED DURING  THE  PERIOD  WHEN  THE  HEALTH  CARE
PROFESSIONAL  WAS  PROVISIONALLY  CREDENTIALED;  PROVIDED, HOWEVER, THAT
NOTHING HEREIN SHALL PREVENT A HEALTH CARE PLAN FROM PAYING A CLAIM FROM
A HEALTH  CARE  PROFESSIONAL  WHO  IS  PROVISIONALLY  CREDENTIALED  UPON
SUBMISSION  OF  SUCH  CLAIM.  A  HEALTH  CARE PLAN SHALL NOT DENY, AFTER
APPEAL, A CLAIM FOR SERVICES PROVIDED BY  A  PROVISIONALLY  CREDENTIALED
HEALTH  CARE  PROFESSIONAL  SOLELY  ON THE GROUND THAT THE CLAIM WAS NOT
TIMELY FILED.
  (E) IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED  BY  A  HEALTH
CARE PLAN PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR
TO EXPIRATION OR TERMINATION OF HIS OR HER CONTRACT WITH THE HEALTH CARE
PLAN,  THE  HEALTH  CARE  PROFESSIONAL OR THE GROUP PRACTICE CHANGES THE
ADDRESS OF OR ADDS AN ADDITIONAL LOCATION TO THE  PRACTICE,  HE  OR  SHE
SHALL NOT BE REQUIRED TO REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED
TO FILE NOTICE OF SUCH CHANGE OR ADDITION WITH THE HEALTH CARE PLAN.
  S  2.  Subsection (a) of section 4803 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (a) (1) An insurer which offers a managed  care  product  shall,  upon
request,  make available and disclose to health care professionals writ-
ten application procedures and minimum qualification requirements  which
a  health  care  professional must meet in order to be considered by the
insurer for participation in the  in-network  benefits  portion  of  the
insurer's  network  for  the  managed  care  product.  The insurer shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits portion of the insurer's network for the managed care  product.
An  insurer  shall  complete  review  of  the health care professional's
application to participate in the in-network portion  of  the  insurer's
network  and,  within  ninety  days  of  receiving a health care profes-
sional's completed application to participate in the insurer's  network,
will notify the health care professional as to: (A) whether he or she is
credentialed;  or  (B)  whether  additional  time is necessary to make a

S. 4970--A                          4

determination in spite of the insurer's best efforts  or  because  of  a
failure  of  a  third  party to provide necessary documentation, or non-
routine or unusual circumstances require additional time for review.  In
such  instances  where additional time is necessary because of a lack of
necessary documentation, an insurer shall make every  effort  to  obtain
such  information  as  soon  as possible. PROVIDED, HOWEVER, THAT IF THE
APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP  PRACTICE
OF  HEALTH  CARE  PROFESSIONALS, OR NEW EMPLOYEE OF A FACILITY OPERATING
UNDER ARTICLE TWENTY-EIGHT OR THIRTY-ONE OF THE PUBLIC HEALTH  LAW  THAT
IS  A  PARTICIPATING  PROVIDER  IN THE HEALTH PLAN, AT LEAST ONE OF WHOM
PARTICIPATES IN THE IN-NETWORK  PORTION  OF  AN  INSURER'S  NETWORK,  AN
INSURER  SHALL,  WITHIN  THIRTY  DAYS  OF  RECEIVING  SUCH A HEALTH CARE
PROFESSIONAL'S COMPLETE  APPLICATION  TO  PARTICIPATE  IN  AN  INSURER'S
NETWORK,  INCLUDING  SUBMISSION  OF ALL NECESSARY DOCUMENTATION FROM THE
APPLICANT AND THIRD PARTIES, COMPLETE REVIEW AND NOTIFY THE HEALTH  CARE
PROFESSIONAL AS TO WHETHER HE OR SHE IS CREDENTIALED.
  (2)  If  the  completed  application  of  a newly-licensed health care
professional or a health care professional who has recently relocated to
this state from another state and has not previously practiced  in  this
state,  who  joins a group practice of health care professionals each of
whom participates in the in-network portion of an insurer's network,  is
neither  approved  nor declined within ninety days pursuant to paragraph
one of this subsection, such health care professional  shall  be  deemed
"provisionally  credentialed"  and  may  participate  in  the in-network
portion of an insurer's  network[;  provided,  however,  that  a  provi-
sionally  credentialed  physician  may not be designated as an insured's
primary care physician until such time as the physician has  been  fully
credentialed].  The network participation for a HEALTH CARE PROFESSIONAL
DEEMED provisionally credentialed [health care professional] PURSUANT TO
THIS PARAGRAPH shall begin on the day following  the  ninetieth  day  of
receipt  of  the  completed  application  and shall last until the final
credentialing determination is made  by  the  insurer.  [A  health  care
professional shall only be eligible for provisional credentialing if the
group  practice  of  health  care  professionals notifies the insurer in
writing that, should the application ultimately be  denied,  the  health
care  professional  or the group practice: (A) shall refund any payments
made by the insurer for  in-network  services  provided  by  the  provi-
sionally  credentialed  health care professional that exceed any out-of-
network benefits payable under the insured's contract with the  insurer;
and  (B)] IT SHALL BE UNDERSTOOD THAT PROVISIONALLY CREDENTIALED PROVID-
ERS' REIMBURSEMENT WILL BE APPROVED BUT HELD BY  THE  HEALTH  CARE  PLAN
UNTIL  FINAL  APPROVAL;  PROVIDED,  HOWEVER,  THAT  IF  REIMBURSEMENT IS
DENIED,  THE  PROVISIONALLY  CREDENTIALED  PROVIDER  shall  not   pursue
reimbursement from the insured, except to collect the copayment or coin-
surance  that otherwise would have been payable had the insured received
services from a health care professional participating in the in-network
portion of an insurer's network.  Interest  and  penalties  pursuant  to
section  three  thousand two hundred twenty-four-a of this chapter shall
not be assessed based on the denial of  a  claim  submitted  during  the
period when the health care professional was provisionally credentialed;
provided,  however,  that  nothing  herein shall prevent an insurer from
paying a claim from a health  care  professional  who  is  provisionally
credentialed  upon  submission of such claim. An insurer shall not deny,
after appeal, a claim for services provided by a  provisionally  creden-
tialed  health care professional solely on the ground that the claim was
not timely filed.

S. 4970--A                          5

  (3) IF THE APPLICANT IS A HEALTH CARE PROFESSIONAL WHO  IS  JOINING  A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY  OPERATING  UNDER  ARTICLE  TWENTY-EIGHT OR THIRTY-ONE OF THE PUBLIC
HEALTH LAW THAT IS A PARTICIPATING PROVIDER IN THE HEALTH PLAN, AT LEAST
ONE  OF  WHOM  PARTICIPATES  IN  THE  IN-NETWORK PORTION OF AN INSURER'S
NETWORK, UPON HIS OR HER SUBMISSION OF A COMPLETE APPLICATION TO PARTIC-
IPATE IN THE INSURER'S NETWORK, INCLUDING SUBMISSION  OF  ALL  NECESSARY
DOCUMENTATION  FROM  THE APPLICANT AND THIRD PARTIES, HE OR SHE SHALL BE
DEEMED "PROVISIONALLY CREDENTIALED" AND MAY PARTICIPATE IN  THE  IN-NET-
WORK  PORTION  OF THE INSURER'S NETWORK. THE NETWORK PARTICIPATION FOR A
HEALTH CARE PROFESSIONAL DEEMED PROVISIONALLY CREDENTIALED  PURSUANT  TO
THIS  PARAGRAPH  SHALL  BEGIN  ON  THE DAY FOLLOWING NOTIFICATION BY THE
INSURER THAT THE COMPLETED APPLICATION WAS RECEIVED AND SHALL LAST UNTIL
THE FINAL CREDENTIALING DETERMINATION IS MADE BY THE INSURER.
  (4) IF A HEALTH CARE PROFESSIONAL  IS  DEEMED  "PROVISIONALLY  CREDEN-
TIALED" PURSUANT TO PARAGRAPH TWO OR THREE OF THIS SUBSECTION, HE OR SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME  AS  THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL BE UNDER-
STOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT  WILL  BE
APPROVED  BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL APPROVAL;
PROVIDED, HOWEVER, THAT IF REIMBURSEMENT IS  DENIED,  THE  PROVISIONALLY
CREDENTIALED  PROVIDER  SHALL NOT PURSUE REIMBURSEMENT FROM THE INSURED,
EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
BEEN PAYABLE HAD THE  INSURED  RECEIVED  SERVICES  FROM  A  HEALTH  CARE
PROFESSIONAL  PARTICIPATING  IN  THE  IN-NETWORK PORTION OF AN INSURER'S
NETWORK. INTEREST AND PENALTIES PURSUANT TO SECTION THREE  THOUSAND  TWO
HUNDRED TWENTY-FOUR-A OF THIS CHAPTER SHALL NOT BE ASSESSED BASED ON THE
DENIAL  OF  A  CLAIM  SUBMITTED  DURING  THE PERIOD WHEN THE HEALTH CARE
PROFESSIONAL WAS PROVISIONALLY  CREDENTIALED;  PROVIDED,  HOWEVER,  THAT
NOTHING  HEREIN  SHALL  PREVENT  AN  INSURER  FROM PAYING A CLAIM FROM A
HEALTH  CARE  PROFESSIONAL  WHO  IS  PROVISIONALLY   CREDENTIALED   UPON
SUBMISSION  OF  SUCH  CLAIM.  AN INSURER SHALL NOT DENY, AFTER APPEAL, A
CLAIM FOR SERVICES PROVIDED BY A PROVISIONALLY CREDENTIALED HEALTH  CARE
PROFESSIONAL SOLELY ON THE GROUND THAT THE CLAIM WAS NOT TIMELY FILED.
  (5)  IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY AN INSURER
PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR TO  EXPI-
RATION  OR  TERMINATION  OF  HIS  OR  HER  CONTRACT WITH THE INSURER FOR
PARTICIPATION IN  THE  IN-NETWORK  BENEFITS  PORTION  OF  THE  INSURER'S
NETWORK  FOR A MANAGED CARE PRODUCT, THE HEALTH CARE PROFESSIONAL OR THE
GROUP PRACTICE CHANGES THE ADDRESS OF OR ADDS AN ADDITIONAL LOCATION  TO
THE  PRACTICE,  SUCH  HEALTH  CARE PROFESSIONAL SHALL NOT BE REQUIRED TO
REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED TO FILE NOTICE  OF  SUCH
CHANGE OR ADDITION WITH THE INSURER.
  S 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

S4970B (ACTIVE) - Bill Details

See Assembly Version of this Bill:
A6426B
Current Committee:
Law Section:
Public Health Law
Laws Affected:
Amd §4406-d, Pub Health L; amd §4803, Ins L

S4970B (ACTIVE) - Bill Texts

view summary

Requires health care plans and insurers to provide expedited review of applications of health care professionals who are joining a group practice and grant provisional credentials to such professionals; provides that health care professionals who have received credentials and change the address of or add locations to the practice need only notify the health care plan or insurer of such change or addition.

view sponsor memo
BILL NUMBER:S4970B

TITLE OF BILL: An act to amend the public health law and the
insurance law, in relation to requiring health care plans and insurers
to provide expedited review of applications of health care
professionals who are joining a group practice and grant provisional
credentials to such professionals

PURPOSE OR GENERAL IDEA OF BILL:

Requires health care plans and insurers to provide expedited review of
applications of health care professionals who are joining a group
practice.

SUMMARY OF SPECIFIC PROVISIONS:

Section 1 of the bill amends the section 4406-d of the public health
law.

Section 2 amends section 4803 of the insurance law.

Section 3 establishes the effective date.

JUSTIFICATION:

Currently there is no requirement or incentive for insurance companies
to facilitate the timely processing of enrollment applications from
participating primary care physician groups for individual providers
joining such a group requesting to join the panel. A physician group
is defined as a group of one or more physicians which either has a
group contract with the insurer, but still may still require
individual enrollment, or a group of physicians of which at least one
is a participating provider in the plan. These delays make it
virtually impossible for the incoming physician to see patients until
60, 90 or even 120 days after the initial application, even while
still needing to be a functioning part of the group.

Insurance companies already have such expedited measures for
specialists. There are no existing mechanisms for primary care
physicians, which can cause up to 6 months of delays in credentialing.
Lost revenue, lost physician productivity and untenable working
schedule's for physicians while waiting for insurance approval make
these delays unreasonable. The pressure placed upon physicians groups
to bill visits by non-part providers in their group through their part
providers is strong, and it is not good sound accounting practice in
the long run for either the insurance company or the provider group.
Therefore, temporary credentials, expedited enrollment, and expedited
change in address from previous practice will all help to increase
ease of patient enrollment into the group practice, thereby easing
enrollment into the insurance plan as well. Since this is already
being done for specialist practices, physician groups should have the
same opportunity. Time and money are saved by the insurance companies
from long, redundant enrollment practices.

PRIOR LEGISLATIVE HISTORY:

2013: A.6426 - Referred to Health; S.4978 - Referred to Health.


FISCAL IMPLICATIONS:

None.

EFFECTIVE DATE:

This act shall take effect on the one hundred eightieth day after it
shall have become a law.

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

                                 4970--B

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                               May 2, 2013
                               ___________

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

AN ACT to amend the public health law and the insurance law, in relation
  to requiring health care  plans  and  insurers  to  provide  expedited
  review  of applications of health care professionals who are joining a
  group practice and grant provisional credentials to such professionals

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

  Section  1.  Subdivision 1 of section 4406-d of the public health law,
as amended by chapter 237 of the laws of 2009, is  amended  to  read  as
follows:
  1.  (a)  A  health  care  plan shall, upon request, make available and
disclose to health care professionals written application procedures and
minimum qualification requirements which a health care professional must
meet in order to be considered by the health care plan. The  plan  shall
consult with appropriately qualified health care professionals in devel-
oping  its qualification requirements. A health care plan shall complete
review of the health care professional's application to  participate  in
the  in-network  portion  of  the  health care plan's network and shall,
within ninety days of receiving a health care  professional's  completed
application to participate in the health care plan's network, notify the
health  care  professional as to: (i) whether he or she is credentialed;
or (ii) whether additional time is necessary to make a determination  in
spite  of the health care plan's best efforts or because of a failure of
a third party to provide  necessary  documentation,  or  non-routine  or
unusual  circumstances  require  additional  time  for  review.  In such
instances where additional time is necessary because of a lack of neces-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD09628-05-4

S. 4970--B                          2

sary documentation, a health plan shall make every effort to obtain such
information as soon as possible. PROVIDED, HOWEVER, THAT IF  THE  APPLI-
CANT  IS  A  HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE OF
HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACILITY OPERATING UNDER
ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR ARTICLE THIRTY-ONE OF THE MENTAL
HYGIENE  LAW  THAT  IS  A  PARTICIPATING PROVIDER IN THE HEALTH PLAN, AT
LEAST ONE OF WHOM PARTICIPATES IN THE IN-NETWORK  PORTION  OF  A  HEALTH
CARE  PLAN'S  NETWORK,  A  HEALTH CARE PLAN SHALL, WITHIN THIRTY DAYS OF
RECEIVING SUCH A HEALTH  CARE  PROFESSIONAL'S  COMPLETE  APPLICATION  TO
PARTICIPATE  IN  THE HEALTH CARE PLAN'S NETWORK, INCLUDING SUBMISSION OF
ALL NECESSARY  DOCUMENTATION  FROM  THE  APPLICANT  AND  THIRD  PARTIES,
COMPLETE REVIEW AND NOTIFY THE HEALTH CARE PROFESSIONAL AS TO WHETHER HE
OR SHE IS CREDENTIALED.
  (b)  If  the  completed  application  of  a newly-licensed health care
professional or a health care professional who has recently relocated to
this state from another state and has not previously practiced  in  this
state,  who  joins a group practice of health care professionals each of
whom participates in the in-network portion  of  a  health  care  plan's
network, is neither approved nor declined within ninety days pursuant to
paragraph (a) of this subdivision, the health care professional shall be
deemed  "provisionally  credentialed" and may participate in the in-net-
work portion of the health care plan's network[; provided, however, that
a provisionally credentialed physician  may  not  be  designated  as  an
enrollee's  primary  care physician until such time as the physician has
been fully credentialed]. The network participation for  a  HEALTH  CARE
PROFESSIONAL  DEEMED  provisionally  credentialed  [health  care profes-
sional] PURSUANT TO THIS PARAGRAPH shall begin on the day following  the
ninetieth  day  of  receipt  of the completed application and shall last
until the final credentialing determination is made by the  health  care
plan. [A health care professional shall only be eligible for provisional
credentialing  if  the group practice of health care professionals noti-
fies the health care plan in writing that, should the application  ulti-
mately  be  denied,  the health care professional or the group practice:
(i) shall refund any payments made by the health care plan  for  in-net-
work  services  provided  by  the provisionally credentialed health care
professional that exceed any out-of-network benefits payable  under  the
enrollee's  contract  with  the  health care plan; and (ii)] IT SHALL BE
UNDERSTOOD THAT PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT WILL
BE APPROVED BUT HELD BY THE  HEALTH  CARE  PLAN  UNTIL  FINAL  APPROVAL;
PROVIDED,  HOWEVER,  THAT  IF REIMBURSEMENT IS DENIED, THE PROVISIONALLY
CREDENTIALED PROVIDER shall not pursue reimbursement from the  enrollee,
except  to  collect the copayment that otherwise would have been payable
had the enrollee received  services  from  a  health  care  professional
participating in the in-network portion of a health care plan's network.
Interest  and  penalties  pursuant to section three thousand two hundred
twenty-four-a of the insurance law shall not be assessed  based  on  the
denial  of  a  claim  submitted  during  the period when the health care
professional was provisionally  credentialed;  provided,  however,  that
nothing herein shall prevent a health care plan from paying a claim from
a  health  care  professional  who  is  provisionally  credentialed upon
submission of such claim. A health  care  plan  shall  not  deny,  after
appeal,  a  claim  for services provided by a provisionally credentialed
health care professional solely on the ground that  the  claim  was  not
timely filed.
  (C)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-

S. 4970--B                          3

ITY OPERATING UNDER ARTICLE TWENTY-EIGHT  OF  THIS  CHAPTER  OR  ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE  HEALTH  PLAN,  AT  LEAST ONE OF WHOM PARTICIPATES IN THE IN-NETWORK
PORTION OF A HEALTH CARE PLAN'S NETWORK, UPON HIS OR HER SUBMISSION OF A
COMPLETE  APPLICATION  TO PARTICIPATE IN THE HEALTH CARE PLAN'S NETWORK,
INCLUDING SUBMISSION OF ALL NECESSARY DOCUMENTATION FROM  THE  APPLICANT
AND  THIRD  PARTIES,  HE  OR  SHE SHALL BE DEEMED "PROVISIONALLY CREDEN-
TIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF THE HEALTH CARE
PLAN'S NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL
DEEMED PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN
ON THE DAY FOLLOWING NOTIFICATION BY  THE  HEALTH  CARE  PLAN  THAT  THE
COMPLETED  APPLICATION  WAS  RECEIVED  AND  SHALL  LAST  UNTIL THE FINAL
CREDENTIALING DETERMINATION IS MADE BY THE HEALTH CARE PLAN.
  (D) IF A HEALTH CARE PROFESSIONAL  IS  DEEMED  "PROVISIONALLY  CREDEN-
TIALED"  PURSUANT TO PARAGRAPH (B) OR (C) OF THIS SUBDIVISION, HE OR SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME AS THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL  BE  UNDER-
STOOD  THAT  PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT WILL BE
APPROVED BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL  APPROVAL;
PROVIDED,  HOWEVER,  THAT  IF REIMBURSEMENT IS DENIED, THE PROVISIONALLY
CREDENTIALED PROVIDER SHALL NOT PURSUE REIMBURSEMENT FROM THE  ENROLLEE,
EXCEPT  TO  COLLECT THE COPAYMENT THAT OTHERWISE WOULD HAVE BEEN PAYABLE
HAD THE ENROLLEE RECEIVED  SERVICES  FROM  A  HEALTH  CARE  PROFESSIONAL
PARTICIPATING IN THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK.
INTEREST  AND  PENALTIES  PURSUANT TO SECTION THREE THOUSAND TWO HUNDRED
TWENTY-FOUR-A OF THE INSURANCE LAW SHALL NOT BE ASSESSED  BASED  ON  THE
DENIAL  OF  A  CLAIM  SUBMITTED  DURING  THE PERIOD WHEN THE HEALTH CARE
PROFESSIONAL WAS PROVISIONALLY  CREDENTIALED;  PROVIDED,  HOWEVER,  THAT
NOTHING HEREIN SHALL PREVENT A HEALTH CARE PLAN FROM PAYING A CLAIM FROM
A  HEALTH  CARE  PROFESSIONAL  WHO  IS  PROVISIONALLY  CREDENTIALED UPON
SUBMISSION OF SUCH CLAIM. A HEALTH  CARE  PLAN  SHALL  NOT  DENY,  AFTER
APPEAL,  A  CLAIM  FOR SERVICES PROVIDED BY A PROVISIONALLY CREDENTIALED
HEALTH CARE PROFESSIONAL SOLELY ON THE GROUND THAT  THE  CLAIM  WAS  NOT
TIMELY FILED.
  (E)  IF  A  HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY A HEALTH
CARE PLAN PURSUANT TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR
TO EXPIRATION OR TERMINATION OF HIS OR HER CONTRACT WITH THE HEALTH CARE
PLAN, THE HEALTH CARE PROFESSIONAL OR THE  GROUP  PRACTICE  CHANGES  THE
ADDRESS  OF  OR  ADDS  AN ADDITIONAL LOCATION TO THE PRACTICE, HE OR SHE
SHALL NOT BE REQUIRED TO REAPPLY FOR CERTIFICATION BUT SHALL BE REQUIRED
TO FILE NOTICE OF SUCH CHANGE OR ADDITION WITH THE HEALTH CARE PLAN.
  S 2. Subsection (a) of section 4803 of the insurance law,  as  amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (a)  (1)  An  insurer  which offers a managed care product shall, upon
request, make available and disclose to health care professionals  writ-
ten  application procedures and minimum qualification requirements which
a health care professional must meet in order to be  considered  by  the
insurer  for  participation  in  the  in-network benefits portion of the
insurer's network for  the  managed  care  product.  The  insurer  shall
consult with appropriately qualified health care professionals in devel-
oping its qualification requirements for participation in the in-network
benefits  portion of the insurer's network for the managed care product.
An insurer shall complete  review  of  the  health  care  professional's
application  to  participate  in the in-network portion of the insurer's
network and, within ninety days  of  receiving  a  health  care  profes-
sional's  completed application to participate in the insurer's network,

S. 4970--B                          4

will notify the health care professional as to: (A) whether he or she is
credentialed; or (B) whether additional time  is  necessary  to  make  a
determination  in  spite  of  the insurer's best efforts or because of a
failure  of  a  third  party to provide necessary documentation, or non-
routine or unusual circumstances require additional time for review.  In
such instances where additional time is necessary because of a  lack  of
necessary  documentation,  an  insurer shall make every effort to obtain
such information as soon as possible. PROVIDED,  HOWEVER,  THAT  IF  THE
APPLICANT  IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A GROUP PRACTICE
OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF  A  FACILITY  OPERATING
UNDER   ARTICLE  TWENTY-EIGHT  OF  THE  PUBLIC  HEALTH  LAW  OR  ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW THAT IS A PARTICIPATING PROVIDER IN
THE HEALTH PLAN, AT LEAST ONE OF WHOM  PARTICIPATES  IN  THE  IN-NETWORK
PORTION OF AN INSURER'S NETWORK, AN INSURER SHALL, WITHIN THIRTY DAYS OF
RECEIVING  SUCH  A  HEALTH  CARE  PROFESSIONAL'S COMPLETE APPLICATION TO
PARTICIPATE IN AN INSURER'S NETWORK, INCLUDING SUBMISSION OF ALL  NECES-
SARY DOCUMENTATION FROM THE APPLICANT AND THIRD PARTIES, COMPLETE REVIEW
AND  NOTIFY  THE  HEALTH  CARE  PROFESSIONAL  AS TO WHETHER HE OR SHE IS
CREDENTIALED.
  (2) If the completed  application  of  a  newly-licensed  health  care
professional or a health care professional who has recently relocated to
this  state  from another state and has not previously practiced in this
state, who joins a group practice of health care professionals  each  of
whom  participates in the in-network portion of an insurer's network, is
neither approved nor declined within ninety days pursuant  to  paragraph
one  of  this  subsection, such health care professional shall be deemed
"provisionally credentialed"  and  may  participate  in  the  in-network
portion  of  an  insurer's  network[;  provided,  however, that a provi-
sionally credentialed physician may not be designated  as  an  insured's
primary  care  physician until such time as the physician has been fully
credentialed]. The network participation for a HEALTH CARE  PROFESSIONAL
DEEMED provisionally credentialed [health care professional] PURSUANT TO
THIS  PARAGRAPH  shall  begin  on the day following the ninetieth day of
receipt of the completed application and  shall  last  until  the  final
credentialing  determination  is  made  by  the  insurer. [A health care
professional shall only be eligible for provisional credentialing if the
group practice of health care  professionals  notifies  the  insurer  in
writing  that,  should  the application ultimately be denied, the health
care professional or the group practice: (A) shall refund  any  payments
made  by  the  insurer  for  in-network  services provided by the provi-
sionally credentialed health care professional that exceed  any  out-of-
network  benefits payable under the insured's contract with the insurer;
and (B)] IT SHALL BE UNDERSTOOD THAT PROVISIONALLY CREDENTIALED  PROVID-
ERS'  REIMBURSEMENT  WILL  BE  APPROVED BUT HELD BY THE HEALTH CARE PLAN
UNTIL FINAL  APPROVAL;  PROVIDED,  HOWEVER,  THAT  IF  REIMBURSEMENT  IS
DENIED,   THE  PROVISIONALLY  CREDENTIALED  PROVIDER  shall  not  pursue
reimbursement from the insured, except to collect the copayment or coin-
surance that otherwise would have been payable had the insured  received
services from a health care professional participating in the in-network
portion  of  an  insurer's  network.  Interest and penalties pursuant to
section three thousand two hundred twenty-four-a of this  chapter  shall
not  be  assessed  based  on  the denial of a claim submitted during the
period when the health care professional was provisionally credentialed;
provided, however, that nothing herein shall  prevent  an  insurer  from
paying  a  claim  from  a  health care professional who is provisionally
credentialed upon submission of such claim. An insurer shall  not  deny,

S. 4970--B                          5

after  appeal,  a claim for services provided by a provisionally creden-
tialed health care professional solely on the ground that the claim  was
not timely filed.
  (3)  IF  THE  APPLICANT IS A HEALTH CARE PROFESSIONAL WHO IS JOINING A
GROUP PRACTICE OF HEALTH CARE PROFESSIONALS, OR NEW EMPLOYEE OF A FACIL-
ITY OPERATING UNDER ARTICLE TWENTY-EIGHT OF THE  PUBLIC  HEALTH  LAW  OR
ARTICLE  THIRTY-ONE  OF  THE  MENTAL HYGIENE LAW THAT IS A PARTICIPATING
PROVIDER IN THE HEALTH PLAN, AT LEAST ONE OF WHOM  PARTICIPATES  IN  THE
IN-NETWORK  PORTION  OF AN INSURER'S NETWORK, UPON HIS OR HER SUBMISSION
OF A COMPLETE APPLICATION  TO  PARTICIPATE  IN  THE  INSURER'S  NETWORK,
INCLUDING  SUBMISSION  OF ALL NECESSARY DOCUMENTATION FROM THE APPLICANT
AND THIRD PARTIES, HE OR SHE  SHALL  BE  DEEMED  "PROVISIONALLY  CREDEN-
TIALED"  AND  MAY PARTICIPATE IN THE IN-NETWORK PORTION OF THE INSURER'S
NETWORK. THE NETWORK PARTICIPATION FOR A HEALTH CARE PROFESSIONAL DEEMED
PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH SHALL BEGIN ON THE
DAY FOLLOWING NOTIFICATION BY THE INSURER THAT THE COMPLETED APPLICATION
WAS RECEIVED AND SHALL LAST UNTIL THE FINAL CREDENTIALING  DETERMINATION
IS MADE BY THE INSURER.
  (4)  IF  A  HEALTH  CARE PROFESSIONAL IS DEEMED "PROVISIONALLY CREDEN-
TIALED" PURSUANT TO PARAGRAPH TWO OR THREE OF THIS SUBSECTION, HE OR SHE
MAY NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH
TIME AS THE PHYSICIAN HAS BEEN FULLY CREDENTIALED.  IT SHALL  BE  UNDER-
STOOD  THAT  PROVISIONALLY CREDENTIALED PROVIDERS' REIMBURSEMENT WILL BE
APPROVED BUT  HELD  BY  THE  HEALTH  CARE  PLAN  UNTIL  FINAL  APPROVAL;
PROVIDED,  HOWEVER,  THAT  IF REIMBURSEMENT IS DENIED, THE PROVISIONALLY
CREDENTIALED PROVIDER SHALL NOT PURSUE REIMBURSEMENT FROM  THE  INSURED,
EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
BEEN  PAYABLE  HAD  THE  INSURED  RECEIVED  SERVICES  FROM A HEALTH CARE
PROFESSIONAL PARTICIPATING IN THE IN-NETWORK  PORTION  OF  AN  INSURER'S
NETWORK.  INTEREST  AND PENALTIES PURSUANT TO SECTION THREE THOUSAND TWO
HUNDRED TWENTY-FOUR-A OF THIS CHAPTER SHALL NOT BE ASSESSED BASED ON THE
DENIAL OF A CLAIM SUBMITTED DURING  THE  PERIOD  WHEN  THE  HEALTH  CARE
PROFESSIONAL  WAS  PROVISIONALLY  CREDENTIALED;  PROVIDED, HOWEVER, THAT
NOTHING HEREIN SHALL PREVENT AN INSURER  FROM  PAYING  A  CLAIM  FROM  A
HEALTH   CARE   PROFESSIONAL  WHO  IS  PROVISIONALLY  CREDENTIALED  UPON
SUBMISSION OF SUCH CLAIM. AN INSURER SHALL NOT  DENY,  AFTER  APPEAL,  A
CLAIM  FOR SERVICES PROVIDED BY A PROVISIONALLY CREDENTIALED HEALTH CARE
PROFESSIONAL SOLELY ON THE GROUND THAT THE CLAIM WAS NOT TIMELY FILED.
  (5) IF A HEALTH CARE PROFESSIONAL HAS BEEN CREDENTIALED BY AN  INSURER
PURSUANT  TO THIS SUBDIVISION, AND SUBSEQUENT THERETO BUT PRIOR TO EXPI-
RATION OR TERMINATION OF HIS  OR  HER  CONTRACT  WITH  THE  INSURER  FOR
PARTICIPATION  IN  THE  IN-NETWORK  BENEFITS  PORTION  OF  THE INSURER'S
NETWORK FOR A MANAGED CARE PRODUCT, THE HEALTH CARE PROFESSIONAL OR  THE
GROUP  PRACTICE CHANGES THE ADDRESS OF OR ADDS AN ADDITIONAL LOCATION TO
THE PRACTICE, SUCH HEALTH CARE PROFESSIONAL SHALL  NOT  BE  REQUIRED  TO
REAPPLY  FOR  CERTIFICATION BUT SHALL BE REQUIRED TO FILE NOTICE OF SUCH
CHANGE OR ADDITION WITH THE INSURER.
  S 3. This act shall take effect on the one hundred eightieth day after
it shall have become a law.

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