S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4335
 
                        2019-2020 Regular Sessions
 
                             I N  S E N A T E
 
                               March 7, 2019
                                ___________
 
 Introduced  by  Sen. SALAZAR -- 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 certain application and referral forms for health care plans
 
   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 425 of the laws of 2016, 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 UNIVERSAL HEALTH  CARE  PROFES-
 SIONAL  application [to participate] FOR PARTICIPATION in the in-network
 portion of the health care plan's network and shall, within  sixty  days
 of  receiving  a health care professional's completed UNIVERSAL applica-
 tion 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 because of
 a failure of a third party to provide necessary documentation.  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 and shall make a final determination
 within twenty-one days of receiving the necessary documentation.
   (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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD03362-01-9

 S. 4335                             2
 
 whom  participates  in  the  in-network  portion of a health care plan's
 network,  is  neither  approved  nor  declined  within  sixty  days   of
 submission  of a completed application pursuant to paragraph (a) of this
 subdivision, the health care professional shall be deemed "provisionally
 credentialed"  and  may  participate  in  the  in-network 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  creden-
 tialed.  The  network  participation  for  a  provisionally credentialed
 health care professional shall begin on the day following  the  sixtieth
 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 creden-
 tialing if the group practice of health care professionals notifies  the
 health  care  plan in writing that, should the application ultimately be
 denied, the health care professional or the group  practice:  (i)  shall
 refund any payments made by the health care plan for in-network 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) 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 thou-
 sand 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) THE COMMISSIONER,  IN  CONSULTATION  WITH  THE  SUPERINTENDENT  OF
 FINANCIAL  SERVICES, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS
 AND HEALTH CARE PROFESSIONALS SHALL ADOPT BY REGULATION  SUCH  UNIVERSAL
 HEALTH  CARE PROFESSIONAL APPLICATION FOR PARTICIPATION FORM, AND A FORM
 FOR THE RENEWAL OF CREDENTIALING WHICH SHALL BE AN  ABBREVIATED  VERSION
 OF  THE  UNIVERSAL  APPLICATION FORM, FOR USE BY HEALTH CARE PLANS WHICH
 OFFER MANAGED CARE PRODUCTS FOR THE PURPOSE OF CREDENTIALING AND RE-CRE-
 DENTIALING HEALTH CARE PROFESSIONALS WHO SEEK TO PARTICIPATE IN A HEALTH
 CARE PLAN'S PROVIDER NETWORK, INCLUDING CREDENTIALING AND RE-CREDENTIAL-
 ING HEALTH CARE PROFESSIONALS WHO ARE EMPLOYED OR HAVE STAFF  PRIVILEGES
 AT  HOSPITALS  OR OTHER HEALTH CARE FACILITIES WHICH SEEK TO PARTICIPATE
 IN A PROVIDER NETWORK.
   (D) THE COMMISSIONER,  IN  CONSULTATION  WITH  THE  SUPERINTENDENT  OF
 FINANCIAL  SERVICES, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS
 AND HEALTH CARE PROFESSIONALS SHALL  ADOPT  BY  REGULATION  A  UNIVERSAL
 HEALTH  CARE  PROFESSIONAL  REFERRAL FORM FOR THE PURPOSE OF SIMPLIFYING
 THE PROCESS OF REFERRAL OF PATIENTS TO OTHER HEALTH CARE PROFESSIONALS.
   (E) THE COMMISSIONER,  IN  CONSULTATION  WITH  THE  SUPERINTENDENT  OF
 FINANCIAL  SERVICES, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS
 AND HEALTH CARE PROFESSIONALS SHALL REVISE  THE  UNIVERSAL  APPLICATION,
 RE-CREDENTIALING  AND  UNIVERSAL HEALTH CARE PROFESSIONAL REFERRAL FORMS
 AS NECESSARY, TO  CONFORM  WITH  INDUSTRY-WIDE,  NATIONAL  STANDARDS  OF
 CREDENTIALING, RE-CREDENTIALING AND HEALTH CARE REFERRAL.

 S. 4335                             3
 
   (F)  IN  DEVELOPING THE UNIVERSAL HEALTH CARE PROFESSIONAL APPLICATION
 RE-CREDENTIALING FORMS, THE COMMISSIONER SHALL ENSURE THAT  THE  CREDEN-
 TIALING AND RE-CREDENTIALING REQUIREMENTS FOR PARTICIPATION IN THE MEDI-
 CAID  PROGRAM  AND  THE  STATE  CHILD HEALTH PLUS PROGRAM ARE ADEQUATELY
 REFLECTED ON THE HEALTH CARE PROFESSIONAL APPLICATION AND RE-CREDENTIAL-
 ING FORMS.
   (G)  ALL  THE  CREDENTIALING  AND  RE-CREDENTIALING FORMS REQUIRED FOR
 DEVELOPMENT UNDER THIS SUBDIVISION SHALL BE THE ONLY FORMS THAT  MAY  BE
 USED FOR CREDENTIALING AND RE-CREDENTIALING HEALTH CARE PROFESSIONALS BY
 HEALTH CARE PLANS, HOSPITALS, AND OTHER HEALTH CARE FACILITIES.
   (H) THE PROFESSIONAL REFERRAL FORM REQUIRED FOR DEVELOPMENT UNDER THIS
 SUBDIVISION SHALL BE THE ONLY FORM THAT A HEALTH CARE PLAN MAY REQUIRE A
 HEALTH  CARE  PROFESSIONAL  TO  USE FOR THE PURPOSES OF MAKING A PROFES-
 SIONAL REFERRAL; PROVIDED, HOWEVER, THAT A HEALTH CARE PLAN MAY  REQUEST
 ADDITIONAL PATIENT INFORMATION SEPARATELY FROM THE PROFESSIONAL REFERRAL
 FORM FOR THE PURPOSES OF REVIEWING SUCH PROFESSIONAL REFERRAL.
   §  2.  Subsection (a) of section 4803 of the insurance law, as amended
 by chapter 425 of the laws of 2016, 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 sixty days of receiving a health care professional'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 because of a failure of a third party to provide necessary
 documentation. 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  and  shall
 make  a  final  determination  within  twenty-one  days of receiving the
 necessary documentation. THE PLANS SHALL ALSO  IMPLEMENT  PROCEDURES  TO
 PERMIT  NEWLY  LICENSED  HEALTH  CARE  PROFESSIONALS  TO RENDER CARE AND
 RECEIVE PAYMENT FOR CARE PROVIDED TO ENROLLEES ON  A  PROVISIONAL  BASIS
 DURING  THE  PENDENCY  OF THE APPLICATION PROCESS OF SUCH NEWLY LICENSED
 HEALTH CARE PROFESSIONALS.
   (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  sixty  days  of  submission  of  a
 completed application 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 provisionally 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 provisionally credentialed health care professional shall begin on the

 S. 4335                             4
 
 day  following  the sixtieth 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 profes-
 sionals notifies the insurer in writing  that,  should  the  application
 ultimately  be  denied,  the health care professional or the group prac-
 tice: (A) shall refund any payments made by the insurer  for  in-network
 services  provided by the provisionally credentialed health care profes-
 sional  that  exceed  any  out-of-network  benefits  payable  under  the
 insured's contract with the insurer; and (B) shall not pursue reimburse-
 ment  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.
   (3)  THE  SUPERINTENDENT,  IN  CONSULTATION  WITH  THE COMMISSIONER OF
 HEALTH, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS, AND  HEALTH
 CARE  PROFESSIONALS  SHALL  ADOPT  BY REGULATION A UNIVERSAL HEALTH CARE
 PROFESSIONAL APPLICATION FOR PARTICIPATION FORM,  AND  A  FORM  FOR  THE
 RENEWAL  OF  CREDENTIALING  WHICH SHALL BE AN ABBREVIATED VERSION OF THE
 UNIVERSAL APPLICATION FORM FOR USE BY  HEALTH  CARE  PLANS  WHICH  OFFER
 MANAGED  CARE  PRODUCTS  FOR THE PURPOSE OF CREDENTIALING AND RE-CREDEN-
 TIALING HEALTH CARE PROFESSIONALS WHO SEEK TO PARTICIPATE  IN  A  HEALTH
 CARE PLAN'S PROVIDER NETWORK, INCLUDING CREDENTIALING AND RE-CREDENTIAL-
 ING  HEALTH CARE PROFESSIONALS WHO ARE EMPLOYED OR HAVE STAFF PRIVILEGES
 AT HOSPITALS OR OTHER HEALTH CARE FACILITIES WHICH SEEK  TO  PARTICIPATE
 IN A PROVIDER NETWORK.
   (4)  THE  SUPERINTENDENT,  IN  CONSULTATION  WITH  THE COMMISSIONER OF
 HEALTH, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS  AND  HEALTH
 CARE  PROFESSIONALS  SHALL  ADOPT  BY REGULATION A UNIVERSAL HEALTH CARE
 PROFESSIONAL REFERRAL FORM FOR THE PURPOSE OF SIMPLIFYING THE PROCESS OF
 REFERRAL OF PATIENTS TO OTHER HEALTH CARE PROFESSIONALS.
   (5) THE SUPERINTENDENT,  IN  CONSULTATION  WITH  THE  COMMISSIONER  OF
 HEALTH,  AND  REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS AND HEALTH
 CARE PROFESSIONALS SHALL REVISE THE  UNIVERSAL  APPLICATION,  RE-CREDEN-
 TIALING  AND UNIVERSAL HEALTH CARE PROFESSIONAL REFERRAL FORMS AS NECES-
 SARY, TO CONFORM WITH INDUSTRY-WIDE, NATIONAL STANDARDS  OF  CREDENTIAL-
 ING, RE-CREDENTIALING AND HEALTH CARE REFERRAL.
   (6)  IN  DEVELOPING THE UNIVERSAL HEALTH CARE PROFESSIONAL APPLICATION
 RE-CREDENTIALING FORMS, THE SUPERINTENDENT SHALL ENSURE THAT THE CREDEN-
 TIALING AND RE-CREDENTIALING REQUIREMENTS FOR PARTICIPATION IN THE MEDI-
 CAID PROGRAM AND THE STATE CHILD  HEALTH  PLUS  PROGRAM  ARE  ADEQUATELY
 REFLECTED ON THE HEALTH CARE PROFESSIONAL APPLICATION AND RE-CREDENTIAL-
 ING FORMS.
   (7) THE CREDENTIALING AND RE-CREDENTIALING FORMS REQUIRED FOR DEVELOP-
 MENT  UNDER THIS SUBSECTION SHALL BE THE ONLY FORMS THAT MAY BE USED FOR
 CREDENTIALING AND RE-CREDENTIALING HEALTH CARE PROFESSIONALS  BY  INSUR-
 ERS, HOSPITALS AND OTHER HEALTH CARE FACILITIES.

 S. 4335                             5
 
   (8) THE PROFESSIONAL REFERRAL FORM REQUIRED FOR DEVELOPMENT UNDER THIS
 SUBSECTION  SHALL  BE THE ONLY FORM THAT AN INSURER MAY REQUIRE A HEALTH
 CARE PROFESSIONAL TO USE FOR  THE  PURPOSES  OF  MAKING  A  PROFESSIONAL
 REFERRAL;  PROVIDED,  HOWEVER,  THAT  AN  INSURER MAY REQUEST ADDITIONAL
 PATIENT  INFORMATION  SEPARATELY FROM THE PROFESSIONAL REFERRAL FORM FOR
 THE PURPOSES OF REVIEWING SUCH PROFESSIONAL REFERRAL.
   § 3. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.