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

                                  2691

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                            January 17, 2013
                               ___________

Introduced  by M. of A. GOTTFRIED, COLTON -- Multi-Sponsored by -- M. of
  A. KELLNER, MONTESANO -- read once and referred 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:

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01431-01-3

              

A. 2691                             2

  1.  An  enrollee,  the  enrollee's  designee  and[, in connection with
retrospective adverse determinations,] an enrollee's health care provid-
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

A. 2691                             3

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  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.

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

                                 2691--A
                                                         Cal. No. 20

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                            January 17, 2013
                               ___________

Introduced  by  M. of A. GOTTFRIED, COLTON, JAFFEE -- Multi-Sponsored by
  -- M. of A.   KELLNER, MONTESANO -- read  once  and  referred  to  the
  Committee on Health -- passed by Assembly and delivered to the Senate,
  recalled  from  the  Senate,  vote reconsidered, bill amended, ordered
  reprinted, retaining its place on the order of third reading

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 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 2. 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,  BUT  NOT LATER THAN WITHIN ONE BUSINESS DAY; SUPPLY
THE PROVIDER WITH A WRITTEN CONFIRMATION 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.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01431-03-3
              

A. 2691--A                          2

  S 3. 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 days] FOUR MONTHS 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 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 4. 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  5.  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, BUT NO LATER THAN WITHIN ONE BUSINESS DAY, SUPPLY THE
PROVIDER WITH A WRITTEN CONFIRMATION 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  6.  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

A. 2691--A                          3

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 days] FOUR MONTHS 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 7.  This act shall take effect July 1, 2014.