Relates to the definition of a clinical peer reviewer by clarifying that such term shall be applicable for the entire utilization review and external appeal article and means either a physician or a health care professional with certain qualifications.
STATE OF NEW YORK
________________________________________________________________________
3076--A
Cal. No. 338
2019-2020 Regular Sessions
IN ASSEMBLY
January 28, 2019
___________
Introduced by M. of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, L. ROSENTHAL,
COLTON, JAFFEE, ABINANTI, D'URSO, LIFTON -- read once and referred to
the Committee on Health -- advanced to a third reading, passed by
Assembly and delivered to the Senate, recalled from the Senate, vote
reconsidered, bill amended, ordered reprinted, retaining its place on
the order of third reading
AN ACT to amend the public health law and the insurance law, in relation
to the definition of clinical peer reviewer
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subdivision 2 of section 4900 of the public health law, as
2 amended by chapter 586 of the laws of 1998, item (B) of subparagraph
3 (ii) of paragraph (a) as amended by chapter 41 of the laws of 2014 and
4 subparagraph (iii) as amended and subparagraph (iv) of paragraph (a) as
5 added by section 42 of subpart A of part BB of chapter 57 of the laws of
6 2019, is amended to read as follows:
7 2. "Clinical peer reviewer" means:
8 (a) [for purposes of title one of this article:
9 (i) a physician who possesses a current and valid non-restricted
10 license to practice medicine; or
11 (ii) a health care professional other than a licensed physician who:
12 (A) where applicable, possesses a current and valid non-restricted
13 license, certificate or registration or, where no provision for a
14 license, certificate or registration exists, is credentialed by the
15 national accrediting body appropriate to the profession; and
16 (B) is in the same profession and same or similar specialty as the
17 health care provider who typically manages the medical condition or
18 disease or provides the health care service or treatment under review;
19 or
20 (iii) for purposes of a determination involving substance use disorder
21 treatment:
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD03373-03-9
A. 3076--A 2
1 (A) a physician who possesses a current and valid non-restricted
2 license to practice medicine and who specializes in behavioral health
3 and has experience in the delivery of substance use disorder courses of
4 treatment; or
5 (B) a health care professional other than a licensed physician who
6 specializes in behavioral health and has experience in the delivery of
7 substance use disorder courses of treatment and, where applicable,
8 possesses a current and valid non-restricted license, certificate or
9 registration or, where no provision for a license, certificate or regis-
10 tration exists, is credentialed by the national accrediting body appro-
11 priate to the profession; or
12 (iv) for purposes of a determination involving treatment for a mental
13 health condition:
14 (A) a physician who possesses a current and valid non-restricted
15 license to practice medicine and who specializes in behavioral health
16 and has experience in the delivery of mental health courses of treat-
17 ment; or
18 (B) a health care professional other than a licensed physician who
19 specializes in behavioral health and has experience in the delivery of a
20 mental health courses of treatment and, where applicable, possesses a
21 current and valid non-restricted license, certificate, or registration
22 or, where no provision for a license, certificate or registration
23 exists, is credentialed by the national accrediting body appropriate to
24 the profession; and
25 (b) for purposes of title two of this article:
26 (i)] a physician who:
27 [(A)] (i) possesses a current and valid non-restricted license to
28 practice medicine under article one hundred thirty-one of the education
29 law;
30 [(B)] (ii) where applicable, is board certified or board eligible in
31 the same or similar specialty as the health care provider who typically
32 manages the medical condition or disease or provides the health care
33 service or treatment under review or appeal;
34 [(C)] (iii) has been practicing in such area of specialty for a period
35 of at least five years; [and]
36 (iv) for purposes of a determination involving substance use disorder
37 treatment, possesses a current and valid non-restricted license to prac-
38 tice medicine and specializes in behavioral health and has experience in
39 the delivery of substance use disorder courses of treatment;
40 (v) for purposes of a determination involving treatment for a mental
41 health condition, possesses a current and valid non-restricted license
42 to practice medicine and who specializes in behavioral health and has
43 experience in the delivery of mental health courses of treatment; and
44 [(D)] (vi) is knowledgeable about the health care service or treatment
45 under review or appeal; or
46 [(ii)] (b) a health care professional other than a licensed physician
47 who possesses a current and valid non-restricted license or certif-
48 ication under title eight of the education law:
49 [(A)] (i) where applicable, possesses a current and valid non-res-
50 tricted license, certificate or registration;
51 [(B)] (ii) where applicable, is credentialed by the national accredit-
52 ing body appropriate to the profession in the same profession and same
53 or similar specialty as the health care provider who typically manages
54 the medical condition or disease or provides the health care service or
55 treatment under review or appeal;
A. 3076--A 3
1 [(C)] (iii) has been practicing in such area of specialty for a period
2 of at least five years;
3 [(D)] (iv) is knowledgeable about the health care service or treatment
4 under review or appeal; [and]
5 (v) for purposes of a determination involving substance use disorder,
6 specializes in behavioral health and has experience in the delivery of
7 substance use disorder courses of treatment and, where applicable,
8 possesses a current and valid non-restricted license, certificate or
9 registration or, where no provision for a license, certificate or regis-
10 tration exists, is credentialed by the national accrediting body appro-
11 priate to the profession;
12 (vi) for purposes of a determination involving treatment for a mental
13 health condition, specializes in behavioral health and has experience in
14 the delivery of mental health courses of treatment and, where applica-
15 ble, possesses a current and valid non-restricted license, certificate,
16 or registration or, where no provision for a license, certificate or
17 registration exists, is credentialed by the national accrediting body
18 appropriate to the profession; and
19 [(E)] (vii) where applicable to such health care professional's scope
20 of practice, is clinically supported by a physician who possesses a
21 current and valid non-restricted license to practice medicine.
22 [(c)] Nothing [herein] in this subdivision shall be construed to
23 change any statutorily-defined scope of practice.
24 § 2. Subsection (b) of section 4900 of the insurance law, as amended
25 by chapter 586 of the laws of 1998, item (ii) of subparagraph (B) of
26 paragraph 1 as amended by chapter 41 of the laws of 2014, subparagraph
27 (C) as amended and subparagraph (D) of paragraph 1 as added by section
28 36 of subpart A of part BB of chapter 57 of the laws of 2019, is amended
29 to read as follows:
30 (b) "Clinical peer reviewer" means:
31 (1) [for purposes of title one of this article:
32 (A) a physician who possesses a current and valid non-restricted
33 license to practice medicine; or
34 (B) a health care professional other than a licensed physician who:
35 (i) where applicable, possesses a current and valid non-restricted
36 license, certificate or registration or, where no provision for a
37 license, certificate or registration exists, is credentialed by the
38 national accrediting body appropriate to the profession; and
39 (ii) is in the same profession and same or similar specialty as the
40 health care provider who typically manages the medical condition or
41 disease or provides the health care service or treatment under review;
42 or
43 (C) for purposes of a determination involving substance use disorder
44 treatment:
45 (i) a physician who possesses a current and valid non-restricted
46 license to practice medicine and who specializes in behavioral health
47 and has experience in the delivery of substance use disorder courses of
48 treatment; or
49 (ii) a health care professional other than a licensed physician who
50 specializes in behavioral health and has experience in the delivery of
51 substance use disorder courses of treatment and, where applicable,
52 possesses a current and valid non-restricted license, certificate or
53 registration or, where no provision for a license, certificate or regis-
54 tration exists, is credentialed by the national accrediting body appro-
55 priate to the profession; or
A. 3076--A 4
1 (D) for purposes of a determination involving treatment for a mental
2 health condition:
3 (i) a physician who possesses a current and valid non-restricted
4 license to practice medicine and who specializes in behavioral health
5 and has experience in the delivery of mental health courses of treat-
6 ment; or
7 (ii) a health care professional other than a licensed physician who
8 specializes in behavioral health and has experience in the delivery of
9 mental health courses of treatment and, where applicable, possesses a
10 current and valid non-restricted license, certificate, or registration
11 or, where no provision for a license, certificate or registration
12 exists, is credentialed by the national accrediting body appropriate to
13 the profession; and
14 (2) for purposes of title two of this article:
15 (A)] a physician who:
16 [(i)] (A) possesses a current and valid non-restricted license to
17 practice medicine under article one hundred thirty-one of the education
18 law;
19 [(ii)] (B) where applicable, is board certified or board eligible in
20 the same or similar specialty as the health care provider who typically
21 manages the medical condition or disease or provides the health care
22 service or treatment under review or appeal;
23 [(iii)] (C) has been practicing in such area of specialty for a period
24 of at least five years; [and]
25 (D) for purposes of a determination involving substance use disorder
26 treatment, possesses a current and valid non-restricted license to prac-
27 tice medicine and who specializes in behavioral health and has experi-
28 ence in the delivery of substance use disorder courses of treatment;
29 (E) for purposes of a determination involving treatment for a mental
30 health condition, possesses a current and valid non-restricted license
31 to practice medicine and who specializes in behavioral health and has
32 experience in the delivery of mental health courses of treatment; and
33 [(iv)] (F) is knowledgeable about the health care service or treatment
34 under review or appeal; or
35 [(B)] (2) a health care professional other than a licensed physician
36 who possesses a current and valid non-restricted license or certif-
37 ication under title eight of the education law:
38 [(i)] (A) where applicable, possesses a current and valid non-res-
39 tricted license, certificate or registration;
40 [(ii)] (B) where applicable, is credentialed by the national accredit-
41 ing body appropriate to the profession in the same profession and same
42 or similar specialty as the health care provider who typically manages
43 the medical condition or disease or provides the health care service or
44 treatment under review or appeal;
45 [(iii)] (C) has been practicing in such area of specialty for a period
46 of at least five years;
47 [(iv)] (D) for purposes of a determination involving substance use
48 disorder treatment, specializes in behavioral health and has experience
49 in the delivery of substance use disorder courses of treatment and,
50 where applicable, possesses a current and valid non-restricted license,
51 certificate or registration or, where no provision for a license,
52 certificate or registration exists, is credentialed by the national
53 accrediting body appropriate to the profession;
54 (E) for purposes of a determination involving treatment for a mental
55 health condition, specializes in behavioral health and has experience in
56 the delivery of mental health courses of treatment and, where applica-
A. 3076--A 5
1 ble, possesses a current and valid non-restricted license, certificate,
2 or registration or, where no provision for a license, certificate or
3 registration exists, is credentialed by the national accrediting body
4 appropriate to the profession;
5 (F) is knowledgeable about the health care service or treatment under
6 review or appeal; and
7 [(v)] (G) where applicable to such health care professional's scope of
8 practice, is clinically supported by a physician who possesses a current
9 and valid non-restricted license to practice medicine.
10 [(3)] Nothing [herein] in this subdivision shall be construed to
11 change any statutorily-defined scope of practice.
12 § 3. This act shall take effect on the same date and in the same
13 manner as subpart A of part BB of chapter 57 of the laws of 2019, or on
14 the ninetieth day after it shall have become a law, whichever is later.