Assembly Bill A9085

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   9085
 
                           I N  A S S E M B L Y
 
                             January 17, 2020
                                ___________
 
 Introduced  by  M.  of  A.  GOTTFRIED  --  read once and referred to the
   Committee on Insurance
 
 AN ACT to amend the insurance law, in relation to  requiring  specifica-
   tion  between  partial  approval  of  medical  claims  and a denial of
   medical claims on written notices to an insurer
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Subsection (b) of section 3224-a of the insurance law, as
 amended by chapter 237 of the laws  of  2009,  is  amended  to  read  as
 follows:
   (b) In a case where the obligation of an insurer or an organization or
 corporation  licensed  or  certified  pursuant to article forty-three or
 forty-seven of this chapter or article forty-four of the  public  health
 law  to  pay a claim or make a payment for health care services rendered
 is not reasonably clear due to a good faith dispute regarding the eligi-
 bility of a person for coverage, the liability  of  another  insurer  or
 corporation  or organization for all or part of the claim, the amount of
 the claim, the benefits covered under a contract or  agreement,  or  the
 manner in which services were accessed or provided, an insurer or organ-
 ization  or corporation shall pay any undisputed portion of the claim in
 accordance with this subsection and  notify  the  policyholder,  covered
 person or health care provider in writing within thirty calendar days of
 the receipt of the claim:
   (1) WHETHER THE CLAIM OR BILL HAS BEEN DENIED OR PARTIALLY APPROVED;
   (2)  WHICH  CLAIM  OR  MEDICAL PAYMENT that it is not obligated to pay
 [the claim or make the medical payment,] stating  the  specific  reasons
 why it is not liable; [or
   (2)] AND
   (3)  to request all additional information needed to determine liabil-
 ity to pay the claim or make the health care payment.
   Upon receipt of the information requested in paragraph [two] THREE  of
 this subsection or an appeal of a claim or bill for health care services
 denied  pursuant  to  [paragraph  one of] this subsection, an insurer or
 organization or corporation licensed or certified  pursuant  to  article
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                       [ ] is old law to be omitted.
                                                            LBD14595-01-9

 A. 9085                             2
 
 forty-three  or forty-seven of this chapter or article forty-four of the
 public health law shall comply with subsection (a) of this section.  ANY
 DENIAL  OR PARTIAL APPROVAL OF CLAIM OR PAYMENT AND THE SPECIFIC REASONS
 FOR SUCH DENIAL OR PARTIAL APPROVAL PURSUANT TO THIS SUBSECTION SHALL BE
 PROMINENTLY  DISPLAYED  ON  A  WRITTEN NOTICE WITH AT LEAST TWELVE-POINT
 TYPE. A PARTIAL APPROVAL OF CLAIM OR PAYMENT SHALL STATE AT THE  TOP  OF
 SUCH  WRITTEN  NOTICE WITH AT LEAST FOURTEEN-POINT TYPE BOLD: "NOTICE OF
 PARTIAL APPROVAL OF MEDICAL COVERAGE". A  DENIAL  OF  CLAIM  OR  PAYMENT
 SHALL  STATE  AT  THE TOP OF SUCH WRITTEN NOTICE WITH AT LEAST FOURTEEN-
 POINT TYPE BOLD: "NOTICE OF DENIAL OF MEDICAL COVERAGE". ANY  ADDITIONAL
 TERMS  OR CONDITIONS INCLUDED ON SUCH NOTICE OF PARTIAL APPROVAL OR SUCH
 NOTICE OF DENIAL, SUCH AS BUT NOT LIMITED TO TIME RESTRAINTS TO FILE  AN
 APPEAL, SHALL BE INCLUDED WITH AT LEAST TWELVE-POINT TYPE.
   §  2.  This  act shall take effect on the ninetieth day after it shall
 have become a law and shall apply  to  policies  and  contracts  issued,
 renewed, modified, altered or amended on or after such effective date.