Shortens time frames during which an insurer has to determine whether a pre-authorization request is medically necessary from three business days to three days.
STATE OF NEW YORK
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4362
2023-2024 Regular Sessions
IN SENATE
February 7, 2023
___________
Introduced by Sen. FERNANDEZ -- 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 shortening time frames during which an insurer has to determine
whether a pre-authorization request is medically necessary
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Paragraph 1 of subsection (b) of section 4903 of the insur-
2 ance law, as separately amended by section 16 of part YY and section 7
3 of part KKK of chapter 56 of the laws of 2020, is amended to read as
4 follows:
5 (1) A utilization review agent shall make a utilization review deter-
6 mination involving health care services which require pre-authorization
7 and provide notice of a determination to the insured or insured's desig-
8 nee and the insured's health care provider by telephone and in writing
9 within three [business] days of receipt of the necessary information, or
10 for inpatient rehabilitation services following an inpatient hospital
11 admission provided by a hospital or skilled nursing facility, within one
12 business day of receipt of the necessary information. The notification
13 shall identify: (i) whether the services are considered in-network or
14 out-of-network; (ii) whether the insured will be held harmless for the
15 services and not be responsible for any payment, other than any applica-
16 ble co-payment, co-insurance or deductible; (iii) as applicable, the
17 dollar amount the health care plan will pay if the service is out-of-
18 network; and (iv) as applicable, information explaining how an insured
19 may determine the anticipated out-of-pocket cost for out-of-network
20 health care services in a geographical area or zip code based upon the
21 difference between what the health care plan will reimburse for out-of-
22 network health care services and the usual and customary cost for out-
23 of-network health care services.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD08682-01-3
S. 4362 2
1 § 2. Paragraph (a) of subdivision 2 of section 4903 of the public
2 health law, as separately amended by section 13 of part YY and section 3
3 of part KKK of chapter 56 of the laws of 2020, is amended to read as
4 follows:
5 (a) A utilization review agent shall make a utilization review deter-
6 mination involving health care services which require pre-authorization
7 and provide notice of a determination to the enrollee or enrollee's
8 designee and the enrollee's health care provider by telephone and in
9 writing within three [business] days of receipt of the necessary infor-
10 mation. The notification shall identify; (i) whether the services are
11 considered in-network or out-of-network; (ii) and whether the enrollee
12 will be held harmless for the services and not be responsible for any
13 payment, other than any applicable co-payment or co-insurance; (iii) as
14 applicable, the dollar amount the health care plan will pay if the
15 service is out-of-network; and (iv) as applicable, information explain-
16 ing how an enrollee may determine the anticipated out-of-pocket cost for
17 out-of-network health care services in a geographical area or zip code
18 based upon the difference between what the health care plan will reim-
19 burse for out-of-network health care services and the usual and custom-
20 ary cost for out-of-network health care services.
21 § 3. This act shall take effect immediately.
