S T A T E O F N E W Y O R K
________________________________________________________________________
2545
2015-2016 Regular Sessions
I N S E N A T E
January 26, 2015
___________
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, OR NEW EMPLOYEE OF A FACILITY OPERATING UNDER
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD01643-01-5
S. 2545 2
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-
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
S. 2545 3
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,
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-
S. 2545 4
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,
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. 2545 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 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.