STATE OF NEW YORK
________________________________________________________________________
7470
2025-2026 Regular Sessions
IN SENATE
April 17, 2025
___________
Introduced by Sens. HOYLMAN-SIGAL, CLEARE, COONEY, GALLIVAN, RIVERA,
SKOUFIS, WEBB -- 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 requiring insurers and health plans to grant automatic preauthori-
zation approvals to eligible health care professionals in certain
circumstances
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subsection (a) of section 4902 of the insurance law is
2 amended by adding a new paragraph 17 to read as follows:
3 (17) Establishment of automatic preauthorization approval requirements
4 for insurers to provide to health care professionals providing health
5 care services which shall include that:
6 (i) an insurer that uses a preauthorization process for health care
7 services shall provide an automatic preauthorization approval to a
8 health care professional for a particular health care service, as
9 defined under this title including but not limited to health care proce-
10 dures, treatments, services, pharmaceutical products, services or dura-
11 ble medical equipment if, in the most recent six-month evaluation peri-
12 od, the insurer has approved not less than ninety percent of the
13 preauthorization requests submitted by such health care professional for
14 the particular health care service. For the purposes of this require-
15 ment, a preauthorization request submitted during the evaluation period
16 shall be considered and counted as a single request and single approval
17 if the request was approved at any point between the date the request
18 was submitted by the health care professional and the final determi-
19 nation by the insurer, including any re-review or appeal process. Each
20 insurer shall complete its initial evaluation and issue its determi-
21 nation to each health care professional in its network no later than one
22 hundred eighty days after the effective date of this paragraph. The
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD01540-02-5
S. 7470 2
1 automatic preauthorization approval shall become effective two hundred
2 twenty-five days after the effective date of this paragraph;
3 (ii) after the initial evaluation has been completed the insurer shall
4 annually thereafter evaluate whether a health care professional quali-
5 fies for an automatic preauthorization approval under subparagraph (i)
6 of this paragraph for additional health care services. Each year, the
7 evaluation shall review preauthorization determinations made in the
8 first six months of the year. Each insurer shall issue its determination
9 to each health care professional in its network no later than November
10 fifteenth to be effective January first of the following year;
11 (iii) the insurer may continue the automatic preauthorization approval
12 under subparagraph (i) of this paragraph without evaluating whether the
13 health care professional qualifies for automatic preauthorization
14 approval for a particular evaluation period;
15 (iv) a health care professional shall not be required to request an
16 automatic preauthorization approval to qualify for such approval;
17 (v) a health care professional's automatic preauthorization approval
18 under subparagraph (i) of this paragraph shall remain in effect until
19 the thirtieth calendar day after:
20 (A) the date the insurer notifies the health care professional of the
21 insurer's determination to rescind the automatic preauthorization
22 approval pursuant to subparagraph (vii) of this paragraph if the health
23 care professional does not appeal such determination; or
24 (B) where the health care professional appeals the determination, the
25 date the insurer notifies the health care professional that an independ-
26 ent review organization has affirmed the insurer's determination to
27 rescind the automatic preauthorization approval;
28 (vi) where an insurer does not finalize a rescission determination as
29 specified in subparagraph (vii) of this paragraph, the health care
30 professional shall be considered to have met the criteria to continue to
31 qualify for the automatic preauthorization approval, which shall remain
32 in effect until the following evaluation period;
33 (vii) an insurer may rescind an automatic preauthorization approval
34 under subparagraph (i) of this paragraph only:
35 (A) effective January of each year;
36 (B) if the insurer makes a determination on the basis of a retrospec-
37 tive review as specified in subparagraph (ii) of this paragraph for the
38 most recent evaluation period that less than ninety percent of the
39 claims for the particular health care service met the medical necessity
40 criteria that would have been used by the insurer when conducting preau-
41 thorization review for the particular health care service during the
42 relevant evaluation period; and
43 (C) the insurer complies with all other applicable requirements of
44 this paragraph and the insurer notifies the health care professional not
45 less than thirty calendar days before the proposed rescission is to take
46 effect, together with the sample of claims used to make the determi-
47 nation pursuant to clause (B) of this subparagraph and a plain language
48 explanation of the health care professional's right to appeal such
49 determination and instructions on how to initiate such appeal;
50 (viii) notwithstanding any contrary provision of subparagraph (i) of
51 this paragraph, an insurer may deny an automatic preauthorization
52 approval:
53 (A) if the health care professional does not have the approval at the
54 time of the relevant evaluation period; and
55 (B) the insurer provides the health care professional with actual
56 statistics and data for the relevant preauthorization request evaluation
S. 7470 3
1 period and detailed information sufficient to demonstrate that the
2 health care professional does not meet the criteria for an automatic
3 preauthorization approval pursuant to subparagraph (i) of this paragraph
4 for the particular health care service;
5 (ix) after a final determination or review affirming the rescission or
6 denial of an automatic preauthorization approval for a specific health
7 care service under this paragraph, a health care professional shall be
8 eligible for consideration of such approval for the same health care
9 service after the evaluation period following the evaluation period
10 which formed the basis of the rescission or denial of such approval;
11 (x) the insurer shall, not later than five business days after deter-
12 mining that a health care professional qualifies for an automatic preau-
13 thorization approval pursuant to subparagraph (i) of this paragraph,
14 provide to a health care professional a notice that shall include:
15 (A) a statement that the health care professional qualifies for an
16 automatic preauthorization approval pursuant to this paragraph;
17 (B) a description of the health care services to which such automatic
18 preauthorization applies; and
19 (C) a statement of the duration that such automatic approval shall
20 remain in effect;
21 (xi) when the health care professional submits a preauthorization
22 request for a health care service for which the health care professional
23 qualifies for an automatic preauthorization approval under subparagraph
24 (i) of this paragraph, the insurer shall promptly issue an automatic
25 preauthorization approval for such health care service;
26 (xii) nothing in this paragraph may be construed to:
27 (A) authorize a health care professional to provide a health care
28 service outside the scope of such health care professional's applicable
29 license; or
30 (B) prohibit a health insurer from performing a retrospective review
31 of the health care service pursuant to section forty-nine hundred three
32 of this title;
33 (xiii) when a health care professional provides a health care service
34 covered by the health care professional's automatic preauthorization
35 approval, the service is deemed medically necessary by virtue of the
36 automatic preauthorization approval. For every claim submitted by a
37 health care professional for such service, each insurer shall promptly
38 pay the full payment to the health care professional. An insurer is
39 prohibited from denying, withholding, or reducing payment to a health
40 care professional for such health care service. An insurer may not
41 retroactively deny, reduce, or recoup payment from a health care profes-
42 sional for such health care service for reasons related to medical
43 necessity or appropriateness of care;
44 (xiv) an insurer may not retroactively deny, reduce, or recoup payment
45 from a health care professional for a health care service for which the
46 health care professional has qualified for an automatic preauthorization
47 approval under subparagraph (i) of this paragraph unless the insurer has
48 proven that the health care professional:
49 (A) knowingly and materially misrepresented the health care service in
50 a request for preauthorization or payment submitted to the insurer with
51 the specific intent to deceive and obtain an unlawful payment from the
52 insurer; or
53 (B) failed to substantially perform the health care service;
54 (xv) an insurer may not retroactively deny, reduce or recoup payment
55 from a health care professional for a health care service for which the
56 health care professional has qualified for an automatic preauthorization
S. 7470 4
1 approval solely on the basis of the rescission of the health care
2 professional's automatic preauthorization approval. Nothing herein shall
3 limit a health care professional's ability to file a complaint with the
4 department;
5 (xvi) the insurer shall make available and submit to the superinten-
6 dent, at the superintendent's request, documentation that describes the
7 insurer's process for:
8 (A) determining the specific health care service or services for which
9 an individual health care professional is granted an automatic preau-
10 thorization approval; and
11 (B) any other activity, policy, decision, or determination related to
12 automatic preauthorization approvals; and
13 (xvii) the superintendent shall promulgate regulations to implement
14 the requirements of this section and establish additional minimum stand-
15 ards as appropriate.
16 § 2. Subdivision 1 of section 4902 of the public health law is amended
17 by adding a new paragraph (m) to read as follows:
18 (m) Establishment of automatic preauthorization approval requirements
19 for health care plans to provide to health care professionals providing
20 certain health care services which shall include that:
21 (i) a health care plan that uses a preauthorization process for health
22 care services shall provide an automatic preauthorization approval to a
23 health care professional for a particular health care service if, as
24 defined under this title including but not limited to health care proce-
25 dures, treatments, services, pharmaceutical products, services or dura-
26 ble medical equipment, in the most recent six-month evaluation period,
27 the health care plan has approved not less than ninety percent of the
28 preauthorization requests submitted by such health care professional for
29 the particular health care service. For the purposes of this require-
30 ment, a preauthorization request submitted during the evaluation period
31 shall be considered and counted as a single request and single approval
32 if the request was approved at any point between the date the request
33 was submitted by the health care professional and the final determi-
34 nation by the health care plan, including any re-review or appeal proc-
35 ess. Each insurer shall complete its initial evaluation and issue its
36 determination to each health care professional in its network no later
37 than one hundred eighty days after the effective date of this paragraph.
38 The automatic preauthorization approval shall become effective two
39 hundred twenty-five days after the effective date of this paragraph;
40 (ii) after the initial evaluation has been completed the health care
41 plan shall annually thereafter evaluate whether a health care profes-
42 sional qualifies for an automatic preauthorization approval under
43 subparagraph (i) of this paragraph for additional health care services.
44 Each year, the evaluation shall review preauthorization determinations
45 made in the first six months of the year. Each health care plan shall
46 issue its determination to each health care professional in its network
47 no later than November fifteenth to be effective January first of the
48 following year;
49 (iii) the health care plan may continue the automatic preauthorization
50 approval under subparagraph (i) of this paragraph without evaluating
51 whether the health care professional qualifies for the automatic preau-
52 thorization approval for a particular evaluation period;
53 (iv) a health care professional shall not be required to request an
54 automatic preauthorization approval to qualify for such approval;
S. 7470 5
1 (v) a health care professional's automatic preauthorization approval
2 under subparagraph (i) of this paragraph shall remain in effect until
3 the thirtieth calendar day after:
4 (A) the date the health care plan notifies the health care profes-
5 sional of the health care plan's determination to rescind the automatic
6 preauthorization approval pursuant to subparagraph (vii) of this para-
7 graph if the health care professional does not appeal such determi-
8 nation; or
9 (B) where the health care professional appeals the determination, the
10 date the health care plan notifies the health care professional that an
11 independent review organization has affirmed the health care plan's
12 determination to rescind the automatic preauthorization approval;
13 (vi) where a health care plan does not finalize a rescission determi-
14 nation as specified in subparagraph (vii) of this paragraph, the health
15 care professional shall be considered to have met the criteria to
16 continue to qualify for the automatic preauthorization approval, which
17 shall remain in effect until the following evaluation period;
18 (vii) a health care plan may rescind an exemption from preauthori-
19 zation requirements under subparagraph (i) of this paragraph only:
20 (A) effective January each year;
21 (B) if the health care plan makes a determination on the basis of a
22 retrospective review as specified in subparagraph (ii) of this paragraph
23 for the most recent evaluation period that less than ninety percent of
24 the claims for the particular health care service met the medical neces-
25 sity criteria that would have been used by the health care plan when
26 conducting preauthorization review for the particular health care
27 service during the relevant evaluation period; and
28 (C) the health care plan complies with all other applicable require-
29 ments of this paragraph and the health care plan notifies the health
30 care professional not less than thirty calendar days before the proposed
31 rescission is to take effect, together with the sample of claims used to
32 make the determination pursuant to clause (B) of this subparagraph and a
33 plain language explanation of the health care professional's right to
34 appeal such determination and instructions on how to initiate such
35 appeal;
36 (viii) notwithstanding any contrary provision of subparagraph (i) of
37 this paragraph, a health care plan may deny an automatic preauthori-
38 zation approval:
39 (A) if the health care professional does not have the approval at the
40 time of the relevant evaluation period; and
41 (B) the health care plan provides the health care professional with
42 actual statistics and data for the relevant preauthorization request
43 evaluation period and detailed information sufficient to demonstrate
44 that the health care professional does not meet the criteria for an
45 automatic preauthorization approval pursuant to subparagraph (i) of this
46 paragraph for the particular health care service;
47 (ix) after a final determination or review affirming the rescission or
48 denial of an automatic preauthorization approval for a specific health
49 care service under this paragraph, a health care professional shall be
50 eligible for consideration of such approval for the same health care
51 service after the evaluation period following the evaluation period
52 which formed the basis of the rescission or denial of such approval;
53 (x) the health care plan shall, not later than five business days
54 after determining that a health care professional qualifies for an auto-
55 matic preauthorization approval pursuant to subparagraph (i) of this
S. 7470 6
1 paragraph, provide to a health care professional a notice that shall
2 include:
3 (A) a statement that the health care professional qualifies for an
4 automatic preauthorization approval pursuant to this paragraph;
5 (B) a description of the health care services to which such automatic
6 preauthorization approval applies; and
7 (C) a statement of the duration that such automatic approval shall
8 remain in effect;
9 (xi) when the health care professional submits a preauthorization
10 request for a health care service for which the health care professional
11 qualifies for an automatic preauthorization approval under subparagraph
12 (i) of this paragraph, the health care plan shall promptly issue an
13 automatic preauthorization approval for such health care service;
14 (xii) nothing in this paragraph shall be construed to:
15 (A) authorize a health care professional to provide a health care
16 service outside the scope of such health care professional's applicable
17 license; or
18 (B) prohibit a health care plan from performing a retrospective review
19 of the health care service pursuant to section forty-nine hundred three
20 of this title;
21 (xiii) when a health care professional provides a health care service
22 covered by the health care professional's automatic preauthorization
23 approval, the service is deemed medically necessary by virtue of the
24 automatic preauthorization approval. For every claim submitted by a
25 health care professional for such service, each health care plan shall
26 promptly pay the full payment to the health care professional. A health
27 care plan is prohibited from denying, withholding, or reducing payment
28 to a health care professional for such health care service. A health
29 care plan may not retroactively deny, reduce, or recoup payment from a
30 health care professional for such health care service for reasons
31 related to medical necessity or appropriateness of care;
32 (xiv) a health care plan may not retroactively deny, reduce, or recoup
33 payment from a health care professional for a health care service for
34 which the health care professional has qualified for an automatic preau-
35 thorization approval under subparagraph (i) of this paragraph unless the
36 health care plan has proven that the health care professional:
37 (A) knowingly and materially misrepresented the health care service in
38 a request for preauthorization or payment submitted to the health care
39 plan with the specific intent to deceive and obtain an unlawful payment
40 from the health care plan; or
41 (B) failed to substantially perform the health care service;
42 (xv) a health care plan may not retroactively deny, reduce or recoup
43 payment from a health care professional for a health care service for
44 which the health care professional has qualified for an automatic preau-
45 thorization approval solely on the basis of the rescission of the health
46 care professional's automatic preauthorization approval. Nothing herein
47 shall limit a health care professional's ability to file a complaint
48 with the department;
49 (xvi) the health care plan shall make available and submit to the
50 commissioner, at the commissioner's request, documentation that
51 describes the health care plan's process for:
52 (A) determining the specific health care service or services for which
53 an individual health care professional is granted an automatic preau-
54 thorization approval; and
55 (B) any other activity, policy, decision, or determination related to
56 automatic preauthorization approvals; and
S. 7470 7
1 (xvii) the commissioner, in consultation with the superintendent,
2 shall promulgate regulations to implement the requirements of this
3 section and establish additional minimum standards as appropriate.
4 § 3. This act shall take effect on the one hundred eightieth day after
5 it shall have become a law.
