S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________

                                         8398

                              2011-2012 Regular Sessions

                                 I N  A S S E M B L Y

                                     June 15, 2011
                                      ___________

       Introduced  by M. of A. RUSSELL -- read once and referred to the Commit-
         tee on Insurance

       AN ACT to amend the insurance law, in relation to provider credentialing

         THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
       BLY, DO ENACT AS FOLLOWS:

    1    Section  1.  Subsection  (a)  of  section 4803 of the insurance law is
    2  amended by adding a new paragraph 3 to read as follows:
    3    (3) A NEWLY-LICENSED HEALTH CARE PROFESSIONAL, A HEALTH  CARE  PROFES-
    4  SIONAL  WHO  HAS RECENTLY RELOCATED TO THIS STATE FROM ANOTHER STATE AND
    5  HAS NOT PREVIOUSLY PRACTICED IN THIS  STATE,  OR  A  PHYSICIAN  WHO  HAS
    6  CHANGED  THEIR  CORPORATE RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSU-
    7  ANCE OF A NEW TAX IDENTIFICATION NUMBER UNDER WHICH THEIR  SERVICES  ARE
    8  BILLED  FOR,  WHO IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO
    9  ARTICLE TWENTY-EIGHT OF THE PUBLIC  HEALTH  LAW,  WHOSE  OTHER  EMPLOYED
   10  HEALTH  CARE  PROFESSIONALS  PARTICIPATE IN THE IN-NETWORK PORTION OF AN
   11  INSURER'S NETWORK, SHALL BE DEEMED "PROVISIONALLY CREDENTIALED" UPON THE
   12  PLAN'S RECEIPT OF THE COMPLETED APPLICATION, AND MAY PARTICIPATE IN  THE
   13  IN-NETWORK  PORTION  OF  AN INSURER'S NETWORK; PROVIDED, HOWEVER, THAT A
   14  PROVISIONALLY  CREDENTIALED  PHYSICIAN  MAY  NOT  BE  DESIGNATED  AS  AN
   15  INSURED'S  PRIMARY  CARE  PHYSICIAN UNTIL SUCH TIME AS THE PHYSICIAN HAS
   16  BEEN FULLY CREDENTIALED BY THE PLAN.  A HEALTH CARE  PROFESSIONAL  SHALL
   17  ONLY  BE  ELIGIBLE FOR PROVISIONAL CREDENTIALING IF THE GENERAL HOSPITAL
   18  LICENSED PURSUANT TO ARTICLE TWENTY-EIGHT OF THE PUBLIC HEALTH LAW  WITH
   19  WHICH  HE  OR  SHE  IS EMPLOYED NOTIFIES THE INSURER IN WRITING THAT THE
   20  HEALTH CARE PROFESSIONAL HAS BEEN GRANTED  HOSPITAL  PRIVILEGES    AFTER
   21  MEETING  THE  REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED FIVE-K OF THE
   22  PUBLIC HEALTH LAW AND, SHOULD THE APPLICATION ULTIMATELY BE DENIED,  THE
   23  LICENSED  GENERAL  HOSPITAL:  (A)  SHALL REFUND ANY PAYMENTS MADE BY THE
   24  INSURER FOR IN-NETWORK SERVICES PROVIDED BY  THE  PROVISIONALLY  CREDEN-
   25  TIALED  HEALTH CARE PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS
   26  PAYABLE UNDER THE INSURED'S CONTRACT WITH THE INSURER; AND (B) SHALL NOT

        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD11200-01-1

 A. 8398                             2

    1  PURSUE REIMBURSEMENT FROM THE INSURED, EXCEPT TO COLLECT  THE  COPAYMENT
    2  OR  COINSURANCE  THAT  OTHERWISE WOULD HAVE BEEN PAYABLE HAD THE INSURED
    3  RECEIVED SERVICES FROM A HEALTH CARE PROFESSIONAL PARTICIPATING  IN  THE
    4  IN-NETWORK PORTION OF AN INSURER'S NETWORK.
    5    S  2.  This  act shall take effect on the ninetieth day after it shall
    6  have become a law, and shall apply to applications submitted after  such
    7  date and shall not apply to applications submitted prior to such date if
    8  such  application  is  resubmitted  in  substantially similar form on or
    9  after the effective date of this act.