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S05834 Summary:

S05834 Actions:

S05834 Floor Votes:

S05834 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          5834
 
                               2013-2014 Regular Sessions
 
                    IN SENATE
 
                                      June 17, 2013
                                       ___________
 
        Introduced  by  Sens.  HANNON, LARKIN -- read twice and ordered printed,
          and when printed to be committed to the Committee on Rules
 
        AN ACT to amend the public health law and the insurance law, in relation
          to approvals by a utilization review agent
 
          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 4903 of the public health law, as
     2  added by chapter 705 of the laws of 1996, is amended to read as follows:
     3    2. A utilization review agent shall make a utilization review determi-
     4  nation  involving  health  care services which require pre-authorization
     5  and provide notice of a determination  to  the  enrollee  or  enrollee's
     6  designee  and  the  enrollee's  health care provider by telephone and in
     7  writing within three business days of receipt of the necessary  informa-
     8  tion.    To  the  extent  practicable,  such written notification to the
     9  enrollee's health care provider shall be transmitted electronically,  in
    10  a manner and in a form agreed upon by the parties.
    11    §  2.  Paragraph  (a)  of  subdivision 2 of section 4914 of the public

    12  health law, as amended by chapter 219 of the laws of 2011, is amended to
    13  read as follows:
    14    (a) The enrollee shall have four months to initiate an external appeal
    15  after the enrollee receives notice from the health care  plan,  or  such
    16  plan's utilization review agent if applicable, of a final adverse deter-
    17  mination  or denial or after both the plan and the enrollee have jointly
    18  agreed to waive any internal appeal, or after the enrollee is deemed  to
    19  have exhausted or is not required to complete any internal appeal pursu-
    20  ant  to  section  2719  of  the  Public  Health Service Act, 42 U.S.C. §
    21  300gg-19. Where applicable, the enrollee's health  care  provider  shall
    22  have  [forty-five]  sixty  days to initiate an external appeal after the
    23  enrollee or the enrollee's health care provider, as applicable, receives

    24  notice from the health care plan,  or  such  plan's  utilization  review
    25  agent if applicable, of a final adverse determination or denial or after
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD01431-06-3
        S. 5834                             2
 
     1  both the plan and the enrollee have jointly agreed to waive any internal
     2  appeal.  Such  request  shall  be  in  writing  in  accordance  with the
     3  instructions and in such form prescribed by  subdivision  five  of  this
     4  section.  The  enrollee,  and  the enrollee's health care provider where
     5  applicable, shall have the opportunity to submit  additional  documenta-
     6  tion with respect to such appeal to the external appeal agent within the

     7  applicable time period above; provided however that when such documenta-
     8  tion  represents a material change from the documentation upon which the
     9  utilization review agent based its adverse determination or  upon  which
    10  the health plan based its denial, the health plan shall have three busi-
    11  ness  days  to  consider  such  documentation  and amend or confirm such
    12  adverse determination.
    13    § 3.  Subsection (b) of section 4903 of the insurance law, as added by
    14  chapter 705 of the laws of 1996, is amended to read as follows:
    15    (b) A utilization review agent shall make a utilization review  deter-
    16  mination  involving health care services which require pre-authorization
    17  and provide notice of a determination to the insured or insured's desig-
    18  nee and the insured's health care provider by telephone and  in  writing

    19  within  three business days of receipt of the necessary information.  To
    20  the extent practicable, such  written  notification  to  the  enrollee's
    21  health  care  provider  shall be transmitted electronically, in a manner
    22  and in a form agreed upon by the parties.
    23    § 4. Paragraph 1 of subsection (b) of section 4914  of  the  insurance
    24  law,  as  amended by chapter 219 of the laws of 2011, is amended to read
    25  as follows:
    26    (1) The insured shall have four months to initiate an external  appeal
    27  after  the  insured  receives  notice from the health care plan, or such
    28  plan's utilization review agent if applicable, of a final adverse deter-
    29  mination or denial, or after both the plan and the insured have  jointly
    30  agreed  to  waive any internal appeal, or after the insured is deemed to

    31  have exhausted or is not required to complete any internal appeal pursu-
    32  ant to section 2719 of the  Public  Health  Service  Act,  42  U.S.C.  §
    33  300gg-19.  Where  applicable,  the  insured's health care provider shall
    34  have [forty-five] sixty days to initiate an external  appeal  after  the
    35  insured  or  the insured's health care provider, as applicable, receives
    36  notice from the health care plan,  or  such  plan's  utilization  review
    37  agent if applicable, of a final adverse determination or denial or after
    38  both  the plan and the insured have jointly agreed to waive any internal
    39  appeal. Such  request  shall  be  in  writing  in  accordance  with  the
    40  instructions  and  in  such  form  prescribed  by subsection (e) of this
    41  section. The insured, and  the  insured's  health  care  provider  where

    42  applicable,  shall  have the opportunity to submit additional documenta-
    43  tion with respect to such appeal to the external appeal agent within the
    44  applicable time period above; provided however that when such documenta-
    45  tion represents a material change from the documentation upon which  the
    46  utilization  review  agent based its adverse determination or upon which
    47  the health plan based its denial, the health plan shall have three busi-
    48  ness days to consider such  documentation  and  amend  or  confirm  such
    49  adverse determination.
    50    § 5.  This act shall take effect July 1, 2014.