Bill S5834-2013

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

  • Nov 13, 2013: SIGNED CHAP.514
  • Nov 1, 2013: DELIVERED TO GOVERNOR
  • Jun 21, 2013: returned to senate
  • Jun 21, 2013: passed assembly
  • Jun 21, 2013: ordered to third reading cal.20
  • Jun 21, 2013: substituted for a2691b
  • Jun 20, 2013: referred to health
  • Jun 20, 2013: DELIVERED TO ASSEMBLY
  • Jun 20, 2013: PASSED SENATE
  • Jun 20, 2013: ORDERED TO THIRD READING CAL.1551
  • Jun 17, 2013: REFERRED TO RULES

Votes

Memo

BILL NUMBER:S5834

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 Subdivision 2 of § 4903 of the public health law to require written notification to the enrollee's health care provider be transmitted electronically, to the extent practicable, in a manner and form agreed to by the parties.

Section 2 amends Subdivision 2 of § 4914 of the public health law to extend the external appeal provider timeframe from 45 days to 60 days.

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

Section 5 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 law requires a utilization review agent to provide notice of a claim determination to the enrollee or the enrollee's designee and the enrollee's health care provider by telephone and in writing within three business days of receipt of the necessary information for preauthorization. Sections 1 and 3 of the bill require such written notice to be transmitted electronically, to the extent practicable. Such electronic transmissions would decrease the administrative cost of health care services and provide a record of utilization review agents' compliance with this requirement.

Sections 2 and 4 of the bill provide a longer timeframe for providers 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 a greater balance by lengthening the providers' timeframe for an external appeal to 60 days.

LEGISLATIVE HISTORY: New bill.

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE: This act shall take effect on July 1, 2014.


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: Section 1. Subdivision 2 of section 4903 of the public health law, as added by chapter 705 of the laws of 1996, is amended to read as follows: 2. A utilization review agent shall make a utilization review determi- nation involving health care services which require pre-authorization and provide notice of a determination to the enrollee or enrollee's designee and the enrollee's health care provider by telephone and in writing within three business days of receipt of the necessary informa- tion. TO THE EXTENT PRACTICABLE, SUCH WRITTEN NOTIFICATION TO THE ENROLLEE'S HEALTH CARE PROVIDER SHALL BE TRANSMITTED ELECTRONICALLY, IN A MANNER AND IN A FORM AGREED UPON BY THE PARTIES. S 2. 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] SIXTY days 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 3. Subsection (b) of section 4903 of the insurance law, as added by chapter 705 of the laws of 1996, is amended to read as follows: (b) A utilization review agent shall make a utilization review deter- mination involving health care services which require pre-authorization and provide notice of a determination to the insured or insured's desig- nee and the insured's health care provider by telephone and in writing within three business days of receipt of the necessary information. TO THE EXTENT PRACTICABLE, SUCH WRITTEN NOTIFICATION TO THE ENROLLEE'S HEALTH CARE PROVIDER SHALL BE TRANSMITTED ELECTRONICALLY, IN A MANNER AND IN A FORM AGREED UPON BY THE PARTIES. S 4. 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] SIXTY days 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 5. This act shall take effect July 1, 2014.

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