senate Bill S5834

Signed By Governor
2013-2014 Legislative Session

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

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Archive: Last Bill Status - Signed by Governor


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

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Actions

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Nov 13, 2013 signed chap.514
Nov 01, 2013 delivered to governor
Jun 21, 2013 returned to senate
passed assembly
ordered to third reading cal.20
substituted for a2691b
Jun 20, 2013 referred to health
delivered to assembly
passed senate
ordered to third reading cal.1551
Jun 17, 2013 referred to rules

Votes

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Co-Sponsors

S5834 - Bill Details

See Assembly Version of this Bill:
A2691B
Law Section:
Public Health Law
Laws Affected:
Amd §§4903 & 4914, Pub Health L; amd §§4903 & 4914, Ins L
Versions Introduced in Previous Legislative Sessions:
2011-2012: A659
2009-2010: A792A

S5834 - Bill Texts

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

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BILL NUMBER:S5834

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: This bill amends the public health and insurance laws related
to utilization review and external appeals.

SUMMARY OF PROVISIONS:

Section 1 amends Subdivision 2 of § 4903 of the public health law to
require written notification to the enrollee's health care provider be
transmitted electronically, to the extent practicable, in a manner and
form agreed to by the parties.

Section 2 amends Subdivision 2 of § 4914 of the public health law to
extend the external appeal provider timeframe from 45 days to 60 days.

Sections 3 and 4 make the same changes as Sections 1 and 2 of the bill
in the insurance law.

Section 5 provides for an effective date of 7/1/14.

JUSTIFICATION: This bill is intended to address certain health plan
practices that result in unfair and unilateral reductions of payments
and claims denials. This bill strikes a balance, as it preserves all
health plan rights to review medical necessity, utilization of services,
and claims payment processing but in a manner that provides fairness to
providers and a remedy when certain utilization reviews are misapplied
by health plans.

New York law requires a utilization review agent to provide notice of a
claim determination to the enrollee or the enrollee's designee and the
enrollee's health care provider by telephone and in writing within three
business days of receipt of the necessary information for preauthori-
zation. Sections 1 and 3 of the bill require such written notice to be
transmitted electronically, to the extent practicable. Such electronic
transmissions would decrease the administrative cost of health care
services and provide a record of utilization review agents' compliance
with this requirement.

Sections 2 and 4 of the bill provide a longer timeframe for providers to
submit external appeals. Legislation was enacted in 2011 that codified
New York's external appeal law with the standards in the Patient
Protection and Affordable Care Act. The timeframe for patients or
patients' designees to submit an appeal to the Department of Financial
Services was extended from 45 days to four months. Providers' timeframe
for an external appeal remains at 45 days and this legislation provides
a greater balance by lengthening the providers' timeframe for an
external appeal to 60 days.

LEGISLATIVE HISTORY: New bill.

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE: This act shall take effect on July 1, 2014.

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

                                  5834

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                              June 17, 2013
                               ___________

Introduced  by  Sens.  HANNON, LARKIN -- read twice and ordered printed,
  and when printed to be committed to the Committee on Rules

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.  Subdivision 2 of section 4903 of the public health law, as
added by chapter 705 of the laws of 1996, is amended to read as follows:
  2. A utilization review agent shall make a utilization review determi-
nation  involving  health  care services which require pre-authorization
and provide notice of a determination  to  the  enrollee  or  enrollee's
designee  and  the  enrollee's  health care provider by telephone and in
writing within three business days of receipt of the necessary  informa-
tion.    TO  THE  EXTENT  PRACTICABLE,  SUCH WRITTEN NOTIFICATION TO THE
ENROLLEE'S HEALTH CARE PROVIDER SHALL BE TRANSMITTED ELECTRONICALLY,  IN
A MANNER AND IN A FORM AGREED UPON BY THE PARTIES.
  S  2.  Paragraph  (a)  of  subdivision 2 of section 4914 of the public
health law, as amended by chapter 219 of the laws of 2011, is amended to
read as follows:
  (a) The enrollee shall have four months to initiate an external appeal
after the enrollee receives notice from the health care  plan,  or  such
plan's utilization review agent if applicable, of a final adverse deter-
mination  or denial or after both the plan and the enrollee have jointly
agreed to waive any internal appeal, or after the enrollee is deemed  to
have exhausted or is not required to complete any internal appeal pursu-
ant  to  section  2719  of  the  Public  Health Service Act, 42 U.S.C. S
300gg-19. Where applicable, the enrollee's health  care  provider  shall
have  [forty-five]  SIXTY  days to initiate an external appeal after the
enrollee or the enrollee's health care provider, as applicable, receives
notice from the health care plan,  or  such  plan's  utilization  review
agent if applicable, of a final adverse determination or denial or after

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01431-06-3

S. 5834                             2

both the plan and the enrollee have jointly agreed to waive any internal
appeal.  Such  request  shall  be  in  writing  in  accordance  with the
instructions and in such form prescribed by  subdivision  five  of  this
section.  The  enrollee,  and  the enrollee's health care provider where
applicable, shall have the opportunity to submit  additional  documenta-
tion with respect to such appeal to the external appeal agent within the
applicable time period above; provided however that when such documenta-
tion  represents a material change from the documentation upon which the
utilization review agent based its adverse determination or  upon  which
the health plan based its denial, the health plan shall have three busi-
ness  days  to  consider  such  documentation  and amend or confirm such
adverse determination.
  S 3.  Subsection (b) of section 4903 of the insurance law, as added by
chapter 705 of the laws of 1996, is amended to read as follows:
  (b) A utilization review agent shall make a utilization review  deter-
mination  involving health care services which require pre-authorization
and provide notice of a determination to the insured or insured's desig-
nee and the insured's health care provider by telephone and  in  writing
within  three business days of receipt of the necessary information.  TO
THE EXTENT PRACTICABLE, SUCH  WRITTEN  NOTIFICATION  TO  THE  ENROLLEE'S
HEALTH  CARE  PROVIDER  SHALL BE TRANSMITTED ELECTRONICALLY, IN A MANNER
AND IN A FORM AGREED UPON BY THE PARTIES.
  S 4. Paragraph 1 of subsection (b) of section 4914  of  the  insurance
law,  as  amended by chapter 219 of the laws of 2011, is amended to read
as follows:
  (1) The insured shall have four months to initiate an external  appeal
after  the  insured  receives  notice from the health care plan, or such
plan's utilization review agent if applicable, of a final adverse deter-
mination or denial, or after both the plan and the insured have  jointly
agreed  to  waive any internal appeal, or after the insured is deemed to
have exhausted or is not required to complete any internal appeal pursu-
ant to section 2719 of the  Public  Health  Service  Act,  42  U.S.C.  S
300gg-19.  Where  applicable,  the  insured's health care provider shall
have [forty-five] SIXTY days to initiate an external  appeal  after  the
insured  or  the insured's health care provider, as applicable, receives
notice from the health care plan,  or  such  plan's  utilization  review
agent if applicable, of a final adverse determination or denial or after
both  the plan and the insured have jointly agreed to waive any internal
appeal. Such  request  shall  be  in  writing  in  accordance  with  the
instructions  and  in  such  form  prescribed  by subsection (e) of this
section. The insured, and  the  insured's  health  care  provider  where
applicable,  shall  have the opportunity to submit additional documenta-
tion with respect to such appeal to the external appeal agent within the
applicable time period above; provided however that when such documenta-
tion represents a material change from the documentation upon which  the
utilization  review  agent based its adverse determination or upon which
the health plan based its denial, the health plan shall have three busi-
ness days to consider such  documentation  and  amend  or  confirm  such
adverse determination.
  S 5.  This act shall take effect July 1, 2014.

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