Bill S5256-2013

Regulates the scope, manner and performance of review of claims by utilization review agents

Regulates the scope, manner and performance of review of claims by utilization review agents.

Details

Actions

  • Jan 8, 2014: REFERRED TO HEALTH
  • Jun 21, 2013: COMMITTED TO RULES
  • Jun 10, 2013: ADVANCED TO THIRD READING
  • Jun 5, 2013: 2ND REPORT CAL.
  • Jun 4, 2013: 1ST REPORT CAL.1126
  • May 15, 2013: REFERRED TO HEALTH

Votes

VOTE: COMMITTEE VOTE: - Health - Jun 4, 2013
Ayes (14): Hannon, Ball, Farley, Felder, Fuschillo, Golden, Larkin, Savino, Seward, Young, Rivera, Montgomery, Hassell-Thompson, O'Brien
Ayes W/R (3): Adams, Peralta, Hoylman

Memo

BILL NUMBER:S5256

TITLE OF BILL: An act to amend the public health law and the insurance law, in relation to approvals by a utilization review agent

PURPOSE:

This bill amends the public health and insurance laws related to utilization review and external appeals.

SUMMARY OF PROVISIONS:

Section 1 amends of § 4903 of the public health law to ensure that the failure of a utilization review agent to make a determination shall be deemed an approved claim.

Section 2 adds a new paragraph (b) of Subdivision 5 of § 4905 of the public health law to require that utilization review agents substantiate pre-authorizations in writing, which may be electronic.

Sections 3 amends § 4914 of the public health law to extend the external appeal provider timeframe from 45 days to 4 months in order to conform with recent changes to related patient timeframes.

Sections 4, 5 and 6 make the same changes as Sections 1, 2 and 3 of the bill in the insurance law.

Section 7 - Provides for an effective date of 7/1/14.

JUSTIFICATION:

This bill is intended to address certain health plan practices that result in unfair and unilateral reductions of payments and claims denials. This bill strikes a balance, as it preserves all health plan rights to review medical necessity, utilization of services, and claims payment processing but in a manner that provides fairness to providers and a remedy when certain utilization reviews are misapplied by health plans.

New York State law establishes timeframes for utilization review agents to decide whether to pay a claim. If the deadline is missed, the claim is considered to have received an adverse determination, i.e., payment is denied. At that point, the burden is on the provider who must expend time and additional resources appealing the plan's silence. Sections 1 and 4 of this bill specify that plan silence, in response to a submitted claim, is an approved claim rather than a denied claim.

Sections 2 and 5 of the bill require utilization review agents to substantiate pre-authorizations in writing. Chapter 451 of 2007 required a managed care organization to pay for care that it pre-authorized (with limited exceptions). However, there is no requirement that pre-authorizations be provided in writing. In many cases, providers receive the pre-authorization verbally. This section requires verbal pre-authorizations to be confirmed in writing by email, fax or posting on a website to avoid confusion and extra administrative follow-up.

Sections 3 and 6 of the bill conform and harmonize the timeframes for providers and patients/patients' designees to submit external appeals. Legislation was enacted in 2011 that codified New York's external appeal law with the standards in the Patient Protection and Affordable Care Act. The timeframe for patients or patients' designees to submit an appeal to the Department of Financial Services was extended from 45 days to four months. Providers' timeframe for an external appeal remains at 45 days and this legislation provides conforming time frames for patients and providers.

LEGISLATIVE HISTORY:

New bill.

FISCAL IMPLICATIONS:

None.

EFFECTIVE DATE:

This act shall take effect on July 1, 2014.


Text

STATE OF NEW YORK ________________________________________________________________________ 5256 2013-2014 Regular Sessions IN SENATE May 15, 2013 ___________
Introduced by Sen. HANNON -- read twice and ordered printed, and when printed to be committed to the Committee on Health 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: Section 1. Subdivision 7 of section 4903 of the public health law, as added by chapter 586 of the laws of 1998, is amended to read as follows: 7. Failure by the utilization review agent to make a determination within the time periods prescribed in this section shall be deemed to be an [adverse determination subject to appeal pursuant to section forty nine hundred four of this title] APPROVAL. S 2. The opening paragraph of subdivision 5 of section 4905 of the public health law is designated paragraph (a) and a new paragraph (b) is added to read as follows: (B) WHENEVER A UTILIZATION REVIEW AGENT MAKES A VERBAL REPRESENTATION REGARDING PREAUTHORIZATION OR APPROVAL, THE UTILIZATION REVIEW AGENT SHALL IMMEDIATELY, BUT NOT LATER THAN WITHIN ONE BUSINESS DAY; SUPPLY THE PROVIDER WITH A WRITTEN CONFIRMATION OF THE APPROVAL BY EITHER: (I) SENDING A COPY OF SUCH APPROVAL THROUGH ELECTRONIC MAIL TO AN ADDRESS SPECIFIED BY THE PROVIDER; (II) SENDING A COPY OF SUCH APPROVAL THROUGH FACSIMILE TRANSMISSION TO A NUMBER SPECIFIED BY THE PROVIDER; OR (III) POSTING A COPY OF SUCH APPROVAL ON A SPECIFIC WEBPAGE OF THE INSURER'S WEBSITE TO WHICH THE PROVIDER HAS BEEN DIRECTED AND TO WHICH THE PROVIDER HAS BEEN GIVEN ACCESS SO THAT THE PROVIDER MAY IMMEDIATELY PRINT AND RETAIN A HARD COPY. S 3. Paragraph (a) of subdivision 2 of section 4914 of the public health law, as amended by chapter 219 of the laws of 2011, is amended to read as follows:
(a) The enrollee shall have four months to initiate an external appeal after the enrollee receives notice from the health care plan, or such plan's utilization review agent if applicable, of a final adverse deter- mination or denial or after both the plan and the enrollee have jointly agreed to waive any internal appeal, or after the enrollee is deemed to have exhausted or is not required to complete any internal appeal pursu- ant to section 2719 of the Public Health Service Act, 42 U.S.C. S 300gg-19. Where applicable, the enrollee's health care provider shall have [forty-five days] FOUR MONTHS to initiate an external appeal after the enrollee or the enrollee's health care provider, as applicable, receives notice from the health care plan, or such plan's utilization review agent if applicable, of a final adverse determination or denial or after both the plan and the enrollee have jointly agreed to waive any internal appeal. Such request shall be in writing in accordance with the instructions and in such form prescribed by subdivision five of this section. The enrollee, and the enrollee's health care provider where applicable, shall have the opportunity to submit additional documenta- tion with respect to such appeal to the external appeal agent within the applicable time period above; provided however that when such documenta- tion represents a material change from the documentation upon which the utilization review agent based its adverse determination or upon which the health plan based its denial, the health plan shall have three busi- ness days to consider such documentation and amend or confirm such adverse determination. S 4. Subsection (g) of section 4903 of the insurance law, as added by chapter 586 of the laws of 1998, is amended to read as follows: (g) Failure by the utilization review agent to make a determination within the time periods prescribed in this section shall be deemed to be an [adverse determination subject to appeal pursuant to section four thousand nine hundred four of this title] APPROVAL. S 5. The opening paragraph of subsection (e) of section 4905 of the insurance law is designated paragraph 1 and a new paragraph 2 is added to read as follows: (2) WHENEVER A UTILIZATION REVIEW AGENT MAKES A VERBAL REPRESENTATION REGARDING PREAUTHORIZATION OR APPROVAL, THE UTILIZATION REVIEW AGENT SHALL IMMEDIATELY, BUT NO LATER THAN WITHIN ONE BUSINESS DAY, SUPPLY THE PROVIDER WITH A WRITTEN CONFIRMATION OF THE APPROVAL BY EITHER: (I) SENDING A COPY OF SUCH APPROVAL THROUGH ELECTRONIC MAIL TO AN ADDRESS SPECIFIED BY THE PROVIDER; (II) SENDING A COPY OF SUCH APPROVAL THROUGH FACSIMILE TRANSMISSION TO A NUMBER SPECIFIED BY THE PROVIDER; OR (III) POSTING A COPY OF SUCH APPROVAL ON A SPECIFIC WEBPAGE OF THE INSURER'S WEBSITE TO WHICH THE PROVIDER HAS BEEN DIRECTED AND TO WHICH THE PROVIDER HAS BEEN GIVEN ACCESS SO THAT THE PROVIDER MAY IMMEDIATELY PRINT AND RETAIN A HARD COPY. S 6. Paragraph 1 of subsection (b) of section 4914 of the insurance law, as amended by chapter 219 of the laws of 2011, is amended to read as follows: (1) The insured shall have four months to initiate an external appeal after the insured receives notice from the health care plan, or such plan's utilization review agent if applicable, of a final adverse deter- mination or denial, or after both the plan and the insured have jointly agreed to waive any internal appeal, or after the insured is deemed to have exhausted or is not required to complete any internal appeal pursu- ant to section 2719 of the Public Health Service Act, 42 U.S.C. S 300gg-19. Where applicable, the insured's health care provider shall
have [forty-five days] FOUR MONTHS to initiate an external appeal after the insured or the insured's health care provider, as applicable, receives notice from the health care plan, or such plan's utilization review agent if applicable, of a final adverse determination or denial or after both the plan and the insured have jointly agreed to waive any internal appeal. Such request shall be in writing in accordance with the instructions and in such form prescribed by subsection (e) of this section. The insured, and the insured's health care provider where applicable, shall have the opportunity to submit additional documenta- tion with respect to such appeal to the external appeal agent within the applicable time period above; provided however that when such documenta- tion represents a material change from the documentation upon which the utilization review agent based its adverse determination or upon which the health plan based its denial, the health plan shall have three busi- ness days to consider such documentation and amend or confirm such adverse determination. S 7. This act shall take effect July 1, 2014.

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