Requires specification between partial approval of medical claims or payments and full denial of medical claims or payments on written notices to an insurer or an organization or corporation licensed or certified.
STATE OF NEW YORK
________________________________________________________________________
9085
IN ASSEMBLY
January 17, 2020
___________
Introduced by M. of A. GOTTFRIED -- read once and referred to the
Committee on Insurance
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:
1 Section 1. Subsection (b) of section 3224-a of the insurance law, as
2 amended by chapter 237 of the laws of 2009, is amended to read as
3 follows:
4 (b) In a case where the obligation of an insurer or an organization or
5 corporation licensed or certified pursuant to article forty-three or
6 forty-seven of this chapter or article forty-four of the public health
7 law to pay a claim or make a payment for health care services rendered
8 is not reasonably clear due to a good faith dispute regarding the eligi-
9 bility of a person for coverage, the liability of another insurer or
10 corporation or organization for all or part of the claim, the amount of
11 the claim, the benefits covered under a contract or agreement, or the
12 manner in which services were accessed or provided, an insurer or organ-
13 ization or corporation shall pay any undisputed portion of the claim in
14 accordance with this subsection and notify the policyholder, covered
15 person or health care provider in writing within thirty calendar days of
16 the receipt of the claim:
17 (1) whether the claim or bill has been denied or partially approved;
18 (2) which claim or medical payment that it is not obligated to pay
19 [the claim or make the medical payment,] stating the specific reasons
20 why it is not liable; [or
21 (2)] and
22 (3) to request all additional information needed to determine liabil-
23 ity to pay the claim or make the health care payment.
24 Upon receipt of the information requested in paragraph [two] three of
25 this subsection or an appeal of a claim or bill for health care services
26 denied pursuant to [paragraph one of] this subsection, an insurer or
27 organization or corporation licensed or certified pursuant to article
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD14595-01-9
A. 9085 2
1 forty-three or forty-seven of this chapter or article forty-four of the
2 public health law shall comply with subsection (a) of this section. Any
3 denial or partial approval of claim or payment and the specific reasons
4 for such denial or partial approval pursuant to this subsection shall be
5 prominently displayed on a written notice with at least twelve-point
6 type. A partial approval of claim or payment shall state at the top of
7 such written notice with at least fourteen-point type bold: "NOTICE OF
8 PARTIAL APPROVAL OF MEDICAL COVERAGE". A denial of claim or payment
9 shall state at the top of such written notice with at least fourteen-
10 point type bold: "NOTICE OF DENIAL OF MEDICAL COVERAGE". Any additional
11 terms or conditions included on such notice of partial approval or such
12 notice of denial, such as but not limited to time restraints to file an
13 appeal, shall be included with at least twelve-point type.
14 § 2. This act shall take effect on the ninetieth day after it shall
15 have become a law and shall apply to policies and contracts issued,
16 renewed, modified, altered or amended on or after such effective date.