S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  1677--A
 
                        2021-2022 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 11, 2021
                                ___________
 
 Introduced  by  M.  of  A.  GOTTFRIED  --  read once and referred to the
   Committee on Insurance -- committee discharged, bill amended,  ordered
   reprinted as amended and recommitted to said committee
 
 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  section  8 of part YY of chapter 56 of the laws of 2020, 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, and through the  internet  or
 other electronic means for claims submitted in that manner, within thir-
 ty 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

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD00505-04-1
              

 A. 1677--A                          2
 
   (3)  to request all additional information needed to determine liabil-
 ity to pay the claim or make the health care payment; and
   [(3)]  (4) of the specific type of plan or product the policyholder or
 covered person is enrolled in; provided that  nothing  in  this  section
 shall authorize discrimination based on the source of 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
 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;
 provided, that if the insurer or 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 determines  that  payment
 or additional payment is due on the claim, such payment shall be made to
 the  policyholder  or  covered  person  or  health  care provider within
 fifteen days of the determination.  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.