A00443 Summary:

BILL NO    A00443A

SAME AS    No same as 

SPONSOR    Gottfried (MS)

COSPNSR    Cahill, Englebright, Galef, Robinson, Jaffee, Otis, Skoufis

MLTSPNSR   Abbate, Aubry, Brennan, Clark, Colton, Cook, Cymbrowitz, Dinowitz,
           Ortiz, Paulin, Perry, Pretlow, Ramos, Rivera, Titus

Amd S4406-d, Pub Health L; amd S4803, Ins L

Relates to certain application and referral forms for health care plans by
authorizing the commissioner and superintendent of financial services to adopt
regulations for the renewal of credentialing and re-credentialing of newly
licensed health care professionals.
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A00443 Memo:

 BILL NUMBER:  A443A

 TITLE OF BILL :  An act to amend the public health law and the
insurance law, in relation to certain application and referral forms
for health care plans

 PURPOSE OR GENERAL IDEA OF BILL : To streamline and simplify the
process by which physicians and other health care professionals are
credentialed by health care plans and hospitals, as well as to
standardize the referral forms that primary care physicians use to
facilitate care for a patient by a specialist physician.

 SUMMARY OF SPECIFIC PROVISIONS : This bill amends section 4406-d,
subdivision (1) of the Public Health Law to create new paragraphs (b),
(c), (d), (e), (f) and (g) that would establish a process for creating
a standardized credentialing and renewal form for physicians and other
health care professionals to use for the purpose of being accepted and
retained on the panels of health care plans. as well as for the
purpose of obtaining staff privileges at a hospital or other health
care facility which seek to participate in a provider network.  Such
credentialing form would be required to include provisions that would
ensure that the form would be applicable for physician participation
in the networks of government sponsored health plans, including
Medicaid and Child Health Plus. It would also establish a similar
process for creating a uniform referral form that physicians and other
health care professionals may use in referring patients for specialty
care.

 JUSTIFICATION : Physicians currently need to spend an extensive
amount of time completing paperwork in order to be credentialed by
health care plans for participation in their networks, and by
hospitals to be granted employment of staff privileges. Credentialing
is the process by which physicians present documentation of their
professional privileges, licensure, evidence of malpractice insurance
and malpractice history to such health care plan or hospital for their
review. While this is an important process for ensuring that a
physician who will provide care for the enrollees of a health plan, or
of the patients at a hospital. is properly qualified, the process can
be unnecessarily cumbersome. Most insurers have different forms that
essentially ask for the same information, creating additional
unnecessary paperwork for the physician. This legislation would
simplify this cumbersome process to facilitate the creation of a
uniform credentialing and renewal form, and thereby reduce the
administrative burden physicians currently have in completing these
forms. This legislation calls for the forms to be devised with
collaboration by all parties who regularly complete and review these
forms, including health plans, hospitals, physicians and other health
care providers.

Moreover, this legislation would also establish a similar process for
creating a standard referral form that a primary care physician may
use to facilitate making a referral when a patient needs to receive
care from a specialist physician. As with credentialing forms, health
care plans typically have their own referral authorization forms that
are substantially similar, but different such that the physician must
use each plan's form. As with the uniform credentialing forms, a
universal referral form would alleviate some of the administrative
hassles that physicians face in attempting to facilitate necessary
care for their patients.

 PRIOR LEGISLATIVE HISTORY :  2002: A.10483-A - advanced to third
reading 2003-04: A.5013 - passed Assembly 2005-06: A.5405 - passed
Assembly 2007-08: A.8163 - passed Assembly 2009-10: A.764-A - passed
Assembly 2011-2012: A.575- passed Assembly 2013-2014: A2673-A - passed
Assembly

 FISCAL IMPLICATIONS : None

 EFFECTIVE DATE : This act shall take effect 180 days after it shall
have become law.
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A00443 Text:

                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________

                                        443--A

                              2015-2016 Regular Sessions

                                 I N  A S S E M B L Y

                                      (PREFILED)

                                    January 7, 2015
                                      ___________

       Introduced  by M. of A. GOTTFRIED, CAHILL, ENGLEBRIGHT, GALEF, ROBINSON,
         JAFFEE, OTIS -- Multi-Sponsored by -- M. of A. ABBATE, AUBRY, BRENNAN,
         CLARK, COLTON, COOK, CYMBROWITZ,  DINOWITZ,  HEASTIE,  ORTIZ,  PAULIN,
         PERRY,  PRETLOW, RAMOS, RIVERA, TITUS -- read once and referred to the
         Committee on Health -- committee  discharged,  bill  amended,  ordered
         reprinted as amended and recommitted to said committee

       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:

    1    Section 1. Subdivision 1 of section 4406-d of the public  health  law,
    2  as  amended  by  chapter  237 of the laws of 2009, is amended to read as
    3  follows:
    4    1. (a) A health care plan shall,  upon  request,  make  available  and
    5  disclose to health care professionals written application procedures and
    6  minimum qualification requirements which a health care professional must
    7  meet  in  order to be considered by the health care plan. The plan shall
    8  consult with appropriately qualified health care professionals in devel-
    9  oping its qualification requirements. A health care plan shall  complete
   10  review  of  the health care professional's UNIVERSAL HEALTH CARE PROFES-
   11  SIONAL application [to participate] FOR PARTICIPATION in the  in-network
   12  portion  of the health care plan's network and shall, within ninety days
   13  of receiving a health care professional's completed  UNIVERSAL  applica-
   14  tion to participate in the health care plan's network, notify the health
   15  care  professional as to: (i) whether he or she is credentialed; or (ii)
   16  whether additional time is necessary to make a determination in spite of
   17  the health care plan's best efforts or because of a failure of  a  third
   18  party  to  provide  necessary  documentation,  or non-routine or unusual
   19  circumstances require additional time  for  review.  In  such  instances
   20  where  additional  time  is  necessary  because  of  a lack of necessary

        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD02406-02-5
       A. 443--A                           2

    1  documentation, a health plan shall make  every  effort  to  obtain  such
    2  information as soon as possible.
    3    (b)  If  the  completed  application  of  a newly-licensed health care
    4  professional or a health care professional who has recently relocated to
    5  this state from another state and has not previously practiced  in  this
    6  state,  who  joins a group practice of health care professionals each of
    7  whom participates in the in-network portion  of  a  health  care  plan's
    8  network, is neither approved nor declined within ninety days pursuant to
    9  paragraph (a) of this subdivision, the health care professional shall be
   10  deemed  "provisionally  credentialed" and may participate in the in-net-
   11  work portion of the health care plan's network; provided, however,  that
   12  a  provisionally  credentialed  physician  may  not  be designated as an
   13  enrollee's primary care physician until such time as the  physician  has
   14  been  fully  credentialed. The network participation for a provisionally
   15  credentialed health care professional shall begin on the  day  following
   16  the ninetieth day of receipt of the completed application and shall last
   17  until  the  final credentialing determination is made by the health care
   18  plan. A health care professional shall only be eligible for  provisional
   19  credentialing  if  the group practice of health care professionals noti-
   20  fies the health care plan in writing that, should the application  ulti-
   21  mately  be  denied,  the health care professional or the group practice:
   22  (i) shall refund any payments made by the health care plan  for  in-net-
   23  work  services  provided  by  the provisionally credentialed health care
   24  professional that exceed any out-of-network benefits payable  under  the
   25  enrollee's contract with the health care plan; and (ii) shall not pursue
   26  reimbursement  from  the  enrollee, except to collect the copayment that
   27  otherwise would have been payable had  the  enrollee  received  services
   28  from  a health care professional participating in the in-network portion
   29  of a health care plan's network.  Interest  and  penalties  pursuant  to
   30  section  three  thousand  two hundred twenty-four-a of the insurance law
   31  shall not be assessed based on the denial of a  claim  submitted  during
   32  the  period  when the health care professional was provisionally creden-
   33  tialed; provided, however, that nothing herein shall  prevent  a  health
   34  care  plan  from  paying  a claim from a health care professional who is
   35  provisionally credentialed upon submission of such claim. A health  care
   36  plan  shall  not  deny, after appeal, a claim for services provided by a
   37  provisionally credentialed health care professional solely on the ground
   38  that the claim was not timely filed.
   39    (C) THE COMMISSIONER,  IN  CONSULTATION  WITH  THE  SUPERINTENDENT  OF
   40  FINANCIAL  SERVICES, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS
   41  AND HEALTH CARE PROFESSIONALS SHALL ADOPT BY REGULATION  SUCH  UNIVERSAL
   42  HEALTH  CARE PROFESSIONAL APPLICATION FOR PARTICIPATION FORM, AND A FORM
   43  FOR THE RENEWAL OF CREDENTIALING WHICH SHALL BE AN  ABBREVIATED  VERSION
   44  OF  THE  UNIVERSAL  APPLICATION FORM, FOR USE BY HEALTH CARE PLANS WHICH
   45  OFFER MANAGED CARE PRODUCTS FOR THE PURPOSE OF CREDENTIALING AND RE-CRE-
   46  DENTIALING HEALTH CARE PROFESSIONALS WHO SEEK TO PARTICIPATE IN A HEALTH
   47  CARE PLAN'S PROVIDER NETWORK, INCLUDING CREDENTIALING AND RE-CREDENTIAL-
   48  ING HEALTH CARE PROFESSIONALS WHO ARE EMPLOYED OR HAVE STAFF  PRIVILEGES
   49  AT  HOSPITALS  OR OTHER HEALTH CARE FACILITIES WHICH SEEK TO PARTICIPATE
   50  IN A PROVIDER NETWORK.
   51    (D) THE COMMISSIONER,  IN  CONSULTATION  WITH  THE  SUPERINTENDENT  OF
   52  FINANCIAL  SERVICES, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS
   53  AND HEALTH CARE PROFESSIONALS SHALL  ADOPT  BY  REGULATION  A  UNIVERSAL
   54  HEALTH  CARE  PROFESSIONAL  REFERRAL FORM FOR THE PURPOSE OF SIMPLIFYING
   55  THE PROCESS OF REFERRAL OF PATIENTS TO OTHER HEALTH CARE PROFESSIONALS.
       A. 443--A                           3

    1    (E) THE COMMISSIONER,  IN  CONSULTATION  WITH  THE  SUPERINTENDENT  OF
    2  FINANCIAL  SERVICES, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS
    3  AND HEALTH CARE PROFESSIONALS SHALL REVISE  THE  UNIVERSAL  APPLICATION,
    4  RE-CREDENTIALING  AND  UNIVERSAL HEALTH CARE PROFESSIONAL REFERRAL FORMS
    5  AS  NECESSARY,  TO  CONFORM  WITH  INDUSTRY-WIDE,  NATIONAL STANDARDS OF
    6  CREDENTIALING, RE-CREDENTIALING AND HEALTH CARE REFERRAL.
    7    (F) IN DEVELOPING THE UNIVERSAL HEALTH CARE  PROFESSIONAL  APPLICATION
    8  RE-CREDENTIALING  FORMS,  THE COMMISSIONER SHALL ENSURE THAT THE CREDEN-
    9  TIALING AND RE-CREDENTIALING REQUIREMENTS FOR PARTICIPATION IN THE MEDI-
   10  CAID PROGRAM AND THE STATE CHILD  HEALTH  PLUS  PROGRAM  ARE  ADEQUATELY
   11  REFLECTED ON THE HEALTH CARE PROFESSIONAL APPLICATION AND RE-CREDENTIAL-
   12  ING FORMS.
   13    (G)  ALL  THE  CREDENTIALING  AND  RE-CREDENTIALING FORMS REQUIRED FOR
   14  DEVELOPMENT UNDER THIS SUBDIVISION SHALL BE THE ONLY FORMS THAT  MAY  BE
   15  USED FOR CREDENTIALING AND RE-CREDENTIALING HEALTH CARE PROFESSIONALS BY
   16  HEALTH CARE PLANS, HOSPITALS, AND OTHER HEALTH CARE FACILITIES.
   17    (H) THE PROFESSIONAL REFERRAL FORM REQUIRED FOR DEVELOPMENT UNDER THIS
   18  SUBDIVISION SHALL BE THE ONLY FORM THAT A HEALTH CARE PLAN MAY REQUIRE A
   19  HEALTH  CARE  PROFESSIONAL  TO  USE FOR THE PURPOSES OF MAKING A PROFES-
   20  SIONAL REFERRAL; PROVIDED, HOWEVER, THAT A HEALTH CARE PLAN MAY  REQUEST
   21  ADDITIONAL PATIENT INFORMATION SEPARATELY FROM THE PROFESSIONAL REFERRAL
   22  FORM FOR THE PURPOSES OF REVIEWING SUCH PROFESSIONAL REFERRAL.
   23    S  2.  Subsection (a) of section 4803 of the insurance law, as amended
   24  by chapter 237 of the laws of 2009, is amended to read as follows:
   25    (a) (1) An insurer which offers a managed  care  product  shall,  upon
   26  request,  make available and disclose to health care professionals writ-
   27  ten application procedures and minimum qualification requirements  which
   28  a  health  care  professional must meet in order to be considered by the
   29  insurer for participation in the  in-network  benefits  portion  of  the
   30  insurer's  network  for  the  managed  care  product.  The insurer shall
   31  consult with appropriately qualified health care professionals in devel-
   32  oping its qualification requirements for participation in the in-network
   33  benefits portion of the insurer's network for the managed care  product.
   34  An  insurer  shall  complete  review  of  the health care professional's
   35  application to participate in the in-network portion  of  the  insurer's
   36  network  and,  within  ninety  days  of  receiving a health care profes-
   37  sional's completed application to participate in the insurer's  network,
   38  will notify the health care professional as to: (A) whether he or she is
   39  credentialed;  or  (B)  whether  additional  time is necessary to make a
   40  determination in spite of the insurer's best efforts  or  because  of  a
   41  failure  of  a  third  party to provide necessary documentation, or non-
   42  routine or unusual circumstances require additional time for review.  In
   43  such instances where additional time is necessary because of a  lack  of
   44  necessary  documentation,  an  insurer shall make every effort to obtain
   45  such information as soon as possible.   THE PLANS SHALL  ALSO  IMPLEMENT
   46  PROCEDURES  TO PERMIT NEWLY LICENSED HEALTH CARE PROFESSIONALS TO RENDER
   47  CARE AND RECEIVE PAYMENT FOR CARE PROVIDED TO ENROLLEES ON A PROVISIONAL
   48  BASIS DURING THE PENDENCY OF  THE  APPLICATION  PROCESS  OF  SUCH  NEWLY
   49  LICENSED HEALTH CARE PROFESSIONALS.
   50    (2)  If  the  completed  application  of  a newly-licensed health care
   51  professional or a health care professional who has recently relocated to
   52  this state from another state and has not previously practiced  in  this
   53  state,  who  joins a group practice of health care professionals each of
   54  whom participates in the in-network portion of an insurer's network,  is
   55  neither  approved  nor declined within ninety days pursuant to paragraph
   56  one of this subsection, such health care professional  shall  be  deemed
       A. 443--A                           4

    1  "provisionally  credentialed"  and  may  participate  in  the in-network
    2  portion of an insurer's network; provided, however, that a provisionally
    3  credentialed physician may not be designated  as  an  insured's  primary
    4  care  physician  until such time as the physician has been fully creden-
    5  tialed. The  network  participation  for  a  provisionally  credentialed
    6  health  care professional shall begin on the day following the ninetieth
    7  day of receipt of the completed application and  shall  last  until  the
    8  final  credentialing determination is made by the insurer. A health care
    9  professional shall only be eligible for provisional credentialing if the
   10  group practice of health care  professionals  notifies  the  insurer  in
   11  writing  that,  should  the application ultimately be denied, the health
   12  care professional or the group practice: (A) shall refund  any  payments
   13  made  by  the  insurer  for  in-network  services provided by the provi-
   14  sionally credentialed health care professional that exceed  any  out-of-
   15  network  benefits payable under the insured's contract with the insurer;
   16  and (B) shall not pursue  reimbursement  from  the  insured,  except  to
   17  collect  the  copayment  or  coinsurance  that otherwise would have been
   18  payable had the insured received services from  a  health  care  profes-
   19  sional  participating in the in-network portion of an insurer's network.
   20  Interest and penalties pursuant to section three  thousand  two  hundred
   21  twenty-four-a  of this chapter shall not be assessed based on the denial
   22  of a claim submitted during the period when the health care professional
   23  was provisionally credentialed; provided, however, that  nothing  herein
   24  shall  prevent an insurer from paying a claim from a health care profes-
   25  sional who is provisionally credentialed upon submission of such  claim.
   26  An  insurer  shall not deny, after appeal, a claim for services provided
   27  by a provisionally credentialed health care professional solely  on  the
   28  ground that the claim was not timely filed.
   29    (3)  THE  SUPERINTENDENT,  IN  CONSULTATION  WITH  THE COMMISSIONER OF
   30  HEALTH, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS, AND  HEALTH
   31  CARE  PROFESSIONALS  SHALL  ADOPT  BY REGULATION A UNIVERSAL HEALTH CARE
   32  PROFESSIONAL APPLICATION FOR PARTICIPATION FORM,  AND  A  FORM  FOR  THE
   33  RENEWAL  OF  CREDENTIALING  WHICH SHALL BE AN ABBREVIATED VERSION OF THE
   34  UNIVERSAL APPLICATION FORM FOR USE BY  HEALTH  CARE  PLANS  WHICH  OFFER
   35  MANAGED  CARE  PRODUCTS  FOR THE PURPOSE OF CREDENTIALING AND RE-CREDEN-
   36  TIALING HEALTH CARE PROFESSIONALS WHO SEEK TO PARTICIPATE  IN  A  HEALTH
   37  CARE PLAN'S PROVIDER NETWORK, INCLUDING CREDENTIALING AND RE-CREDENTIAL-
   38  ING  HEALTH CARE PROFESSIONALS WHO ARE EMPLOYED OR HAVE STAFF PRIVILEGES
   39  AT HOSPITALS OR OTHER HEALTH CARE FACILITIES WHICH SEEK  TO  PARTICIPATE
   40  IN A PROVIDER NETWORK.
   41    (4)  THE  SUPERINTENDENT,  IN  CONSULTATION  WITH  THE COMMISSIONER OF
   42  HEALTH, AND REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS  AND  HEALTH
   43  CARE  PROFESSIONALS  SHALL  ADOPT  BY REGULATION A UNIVERSAL HEALTH CARE
   44  PROFESSIONAL REFERRAL FORM FOR THE PURPOSE OF SIMPLIFYING THE PROCESS OF
   45  REFERRAL OF PATIENTS TO OTHER HEALTH CARE PROFESSIONALS.
   46    (5) THE SUPERINTENDENT,  IN  CONSULTATION  WITH  THE  COMMISSIONER  OF
   47  HEALTH,  AND  REPRESENTATIVES OF HEALTH CARE PLANS, HOSPITALS AND HEALTH
   48  CARE PROFESSIONALS SHALL REVISE THE  UNIVERSAL  APPLICATION,  RE-CREDEN-
   49  TIALING  AND UNIVERSAL HEALTH CARE PROFESSIONAL REFERRAL FORMS AS NECES-
   50  SARY, TO CONFORM WITH INDUSTRY-WIDE, NATIONAL STANDARDS  OF  CREDENTIAL-
   51  ING, RE-CREDENTIALING AND HEALTH CARE REFERRAL.
   52    (6)  IN  DEVELOPING THE UNIVERSAL HEALTH CARE PROFESSIONAL APPLICATION
   53  RE-CREDENTIALING FORMS, THE SUPERINTENDENT SHALL ENSURE THAT THE CREDEN-
   54  TIALING AND RE-CREDENTIALING REQUIREMENTS FOR PARTICIPATION IN THE MEDI-
   55  CAID PROGRAM AND THE STATE CHILD  HEALTH  PLUS  PROGRAM  ARE  ADEQUATELY
       A. 443--A                           5

    1  REFLECTED ON THE HEALTH CARE PROFESSIONAL APPLICATION AND RE-CREDENTIAL-
    2  ING FORMS.
    3    (7) THE CREDENTIALING AND RE-CREDENTIALING FORMS REQUIRED FOR DEVELOP-
    4  MENT  UNDER THIS SUBSECTION SHALL BE THE ONLY FORMS THAT MAY BE USED FOR
    5  CREDENTIALING AND RE-CREDENTIALING HEALTH CARE PROFESSIONALS  BY  INSUR-
    6  ERS, HOSPITALS AND OTHER HEALTH CARE FACILITIES.
    7    (8) THE PROFESSIONAL REFERRAL FORM REQUIRED FOR DEVELOPMENT UNDER THIS
    8  SUBSECTION  SHALL  BE THE ONLY FORM THAT AN INSURER MAY REQUIRE A HEALTH
    9  CARE PROFESSIONAL TO USE FOR  THE  PURPOSES  OF  MAKING  A  PROFESSIONAL
   10  REFERRAL;  PROVIDED,  HOWEVER,  THAT  AN  INSURER MAY REQUEST ADDITIONAL
   11  PATIENT INFORMATION SEPARATELY FROM THE PROFESSIONAL REFERRAL  FORM  FOR
   12  THE PURPOSES OF REVIEWING SUCH PROFESSIONAL REFERRAL.
   13    S 3. This act shall take effect on the one hundred eightieth day after
   14  it shall have become a law.
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