S T A T E O F N E W Y O R K
________________________________________________________________________
629
2015-2016 Regular Sessions
I N S E N A T E
(PREFILED)
January 7, 2015
___________
Introduced by Sen. VALESKY -- read twice and ordered printed, and when
printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law and the public health law, in relation
to provider credentialing
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subsection (a) of section 4803 of the insurance law is
amended by adding a new paragraph 3 to read as follows:
(3) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
TO THIS STATE FROM ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN
THIS STATE, OR A PHYSICIAN WHO HAS CHANGED HIS OR HER CORPORATE
RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
CATION NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO
IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO ARTICLE
TWENTY-EIGHT OF THE PUBLIC HEALTH LAW, AND WHOSE OTHER EMPLOYED PHYSI-
CIANS PARTICIPATE IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK,
SHALL BE DEEMED "PROVISIONALLY CREDENTIALED" AND MAY PARTICIPATE IN THE
IN-NETWORK PORTION OF AN INSURER'S NETWORK UPON : (I) THE INSURER'S
RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTIONS OF THE INSUR-
ER'S CREDENTIALING APPLICATION; AND (II) THE INSURER BEING NOTIFIED IN
WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN GRANTED HOSPITAL
PRIVILEGES PURSUANT TO THEIR REQUIREMENTS OF SECTION TWENTY-EIGHT
HUNDRED FIVE-K OF THE PUBLIC HEALTH LAW. HOWEVER, A PROVISIONALLY
CREDENTIALED PHYSICIAN SHALL NOT BE DESIGNATED AS AN INSURED'S PRIMARY
CARE PHYSICIAN UNTIL SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY CREDEN-
TIALED BY THE INSURER. AN INSURER SHALL NOT BE REQUIRED TO MAKE ANY
PAYMENTS TO THE LICENSED GENERAL HOSPITAL FOR SERVICES PROVIDED BY A
PROVISIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS
FULLY CREDENTIALED BY THE INSURER, PROVIDED, HOWEVER, THAT UPON BEING
FULLY CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD01972-01-5
S. 629 2
SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE INSURER'S
INSUREDS FROM THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE
PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI-
CATION ULTIMATELY BE DENIED BY THE INSURER, THE INSURER SHALL NOT BE
LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPITAL FOR THE SERVICES
PROVIDED BY THE PROVISIONALLY CREDENTIALED HEALTH CARE PROFESSIONAL THAT
EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER THE INSURED'S CONTRACT
WITH THE INSURER; AND THE LICENSED GENERAL HOSPITAL SHALL NOT PURSUE
REIMBURSEMENT FORM 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.
S 2. Subdivision 1 of section 4406-d of the public health law is
amended by adding a new paragraph (c) to read as follows:
(C) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
TO THIS STATE FROM ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN
THIS STATE, OR A PHYSICIAN WHO HAS CHANGED HIS OR HER CORPORATE
RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
CATION NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO
IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO ARTICLE
TWENTY-EIGHT OF THIS CHAPTER, AND WHOSE OTHER EMPLOYED PHYSICIANS
PARTICIPATE IN THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK,
SHALL BE DEEMED "PROVISIONALLY CREDENTIALLED" AND MAY PARTICIPATE IN THE
IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK UPON: (I) THE PLAN'S
RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTION OF THE PLAN'S
CREDENTIALING APPLICATION; AND (II) THE HEALTH CARE PLAN BEING NOTIFIED
IN WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN GRANTED HOSPITAL
PRIVILEGE PURSUANT TO THE REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED
FIVE-K OF THIS CHAPTER. HOWEVER, A PROVISIONALLY CREDENTIALED PHYSICIAN
SHALL NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL
SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY CREDENTIALED BY THE HEALTH
CARE PLAN. A HEALTH CARE PLAN SHALL NOT BE REQUIRED TO MAKE ANY PAYMENTS
TO THE LICENSED GENERAL HOSPITAL FOR SERVICED PROVIDED BY A PROVI-
SIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY
CREDENTIALED BY THE HEALTH CARE PLAN, PROVIDED HOWEVER THAT UPON BEING
FULLY CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL
SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE HEALTH PLAN'S
ENROLLEES FROM THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE
PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI-
CATION ULTIMATELY BE DENIED BY THE HEALTH CARE PLAN, THE HEALTH CARE
PLAN SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPI-
TAL FOR THE 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 THE LICENSED
GENERAL HOSPITAL SHALL NOT PURSUE REIMBURSEMENT FORM THE ENROLLEE,
EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
BEEN PAYABLE HAD THE ENROLLEE RECEIVED SERVICES FROM A HEALTH CARE
PROFESSIONAL PARTICIPATING IN THE IN-NETWORK PORTION OF AN INSURER'S
NETWORK.
S 3. This act shall take effect on the ninetieth day after it shall
have become a law, and shall apply to applications submitted on or after
such date and shall not apply to applications submitted prior to such
date if such application is resubmitted in substantially similar form on
or after the effective date of this act.
