Amd S363-a, Soc Serv L; amd SS3216, 3221 & 4303, Ins L; amd SS2807-p, 4406-d, 2511 & 4408, add S4408-b, Pub
Health L
Relates to filing and payment requirements for HMO claims, payment of claims for medical care, HMO electronic remittance advices, health care professional credentialing, and establishes HMO reporting requirements.
STATE OF NEW YORK
________________________________________________________________________
5245
2011-2012 Regular Sessions
IN ASSEMBLY
February 14, 2011
___________
Introduced by M. of A. P. RIVERA -- read once and referred to the
Committee on Insurance
AN ACT to amend the social services law, the insurance law, and the
public health law, in relation to filing requirements for medical
assistance program claims and HMO claims, payment of claims for
medical care or services, electronic remittance advices, HMO creden-
tialing for health care professionals, and establishing HMO reporting
requirements
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 363-a of the social services law,
2 as amended by chapter 474 of the laws of 1996, is amended to read as
3 follows:
4 2. The department of health shall make such regulations, not incon-
5 sistent with law, as may be necessary to implement this title, provided
6 that no such regulations shall provide that an otherwise valid claim for
7 medical care, services or supplies pursuant to the provisions of this
8 title, shall be deemed invalid and thus ineligible for payment based
9 solely upon the failure of such claim to be submitted within ninety days
10 of the date of service.
11 § 2. Section 3216 of the insurance law is amended by adding a new
12 subsection (m) to read as follows:
13 (m) No insurer shall deny compensation to a participating provider
14 that is not listed as a patient's primary care physician, but has
15 rendered medical care, services or supplies to an insured.
16 § 3. Section 3221 of the insurance law is amended by adding a new
17 subsection (s) to read as follows:
18 (s) No insurer shall deny compensation to a participating provider
19 that is not listed as a patient's primary care physician, but has
20 rendered medical care, services or supplies to an insured.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD08316-02-1
A. 5245 2
1 § 4. Section 4303 of the insurance law is amended by adding a new
2 subsection (hh) to read as follows:
3 (hh) No hospital service corporation, health service corporation,
4 medical expense indemnity corporation, or other insurer which provides
5 coverage for hospital, surgical or medical care shall deny compensation
6 to a participating provider that is not listed as a patient's primary
7 care physician, but has rendered medical care, services or supplies to
8 an insured.
9 § 5. Subdivision 1 of section 2807-p of the public health law is
10 amended by adding a new paragraph (e) to read as follows:
11 (e) Notwithstanding any other provision of this article, if a facility
12 has made a good faith effort to comply with the reporting requirements
13 set forth in this section, and fails to submit such reports or data by
14 the established deadline, such facility shall not be subject to finan-
15 cial penalty, including a delay or disqualification of financial
16 distributions, based solely upon such failure to submit such reports or
17 data.
18 § 6. The public health law is amended by adding a new section 4408-b
19 to read as follows:
20 § 4408-b. Electronic remittance advices. Notwithstanding any other
21 provision of this article, upon receiving an electronic claim for cover-
22 age of a procedure, treatment, supply or service, or any information
23 pertaining to such claim via electronic method, a health maintenance
24 organization licensed pursuant to article forty-three of the insurance
25 law or certified pursuant to this article, shall provide electronic
26 remittance advices to the enrollee, the health care provider and to any
27 necessary parties involved with such claim. For the purposes of this
28 section, "electronic remittance advice" shall mean an electronic version
29 of such information, as described in section four thousand four hundred
30 eight of this article, and an explanation of all details concerning a
31 health maintenance organization's payment or denial of a claim.
32 § 7. Subdivision 1 of section 4406-d of the public health law is
33 amended by adding a new paragraph (c) to read as follows:
34 (c) If the completed application of a health care professional who is:
35 (i) in compliance with the provisions of article one hundred thirty-one
36 of the education law, and (ii) in compliance and in good standing with
37 eligibility requirements set forth by the medical assistance program
38 concerning a health care professional's participation as a medical
39 assistance provider, the health care professional shall be allowed to
40 provide medical care or service and submit claims regarding such medical
41 care or service provided to enrollees participating in the medical
42 assistance program.
43 § 8. Section 2511 of the public health law is amended by adding a new
44 subdivision 21 to read as follows:
45 21. Notwithstanding any other law or agreement to the contrary, if a
46 health care provider or health care center provides medical care,
47 services or supplies to an enrollee of a health maintenance organiza-
48 tion, such provider shall be entitled to submit a claim to the health
49 maintenance organization for payment for such medical care or services
50 and for payment of any "budget balance act" (BBA) or child health plus
51 (CHIP) subsidy payment amounts entitled to such provider. If such claim
52 is subsequently denied by the appropriate organization, the provider
53 shall be entitled to payment for such medical care or services, provided
54 that the patient was an active participant of a health insurance program
55 funded by the department and the medical care or services furnished by
56 such provider were valid.
A. 5245 3
1 § 9. Section 4408 of the public health law is amended by adding two
2 new subdivisions 7 and 8 to read as follows:
3 7. Every thirty days, a health maintenance organization shall provide
4 to all health care providers or health care centers to whom their enrol-
5 lees seek medical care or service, a report containing an explanation of
6 charges, payments and the total number of patients serviced under the
7 family health plus plan, child health plus plan, medicare program and
8 medicaid program.
9 8. All health maintenance organizations shall provide to health care
10 providers and health care centers, an electronic patient roster contain-
11 ing a list of current enrollees eligible to seek medical treatment or
12 services with such health care provider or at such health care center.
13 § 10. This act shall take effect immediately.
