Bill S6281-2013

Requires clinical peer reviewers to be licensed, registered or certified in this state and to be in the same specialty as the health care provider being reviewed

Requires, for purposes of utilization review and external appeals, clinical peer reviewers to be licensed, registered or certified in this state and to be in the same specialty as the health care provider being reviewed.

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  • Jan 9, 2014: REFERRED TO INSURANCE

Memo

BILL NUMBER:S6281         REVISED MEMO 01/10/14

TITLE OF BILL: An act to amend the insurance law and the public health law, in relation to the definitions of "clinical peer reviewer" for the purposes of utilization review and external appeal

PURPOSE:

This bill requires clinical peer reviewers to be licensed, registered or certified in this state.

SUMMARY OF PROVISIONS:

Section 1 - Amends subsection (b) of section 4900 of the insurance law, as amended by chapter 586 of the laws of 1998.

Section 2 Amends subdivision 2 of section 4900 of the public health law, as amended by chapter 586 of the laws of 1998.

Section 3 - Effective date.

JUSTIFICATION:

Clinical peer reviewers of insurance claims are in a position to second guess and deny insurance claims regarding a medical condition or treatment ordered by a patient's physician or other authorized health care provider. This bill would require all clinical peer reviewers conducting utilization review and external appeals for New York patients to be licensed, registered or certified in New York State.

LEGISLATIVE HISTORY:

New bill

FISCAL IMPLICATIONS:

None

EFFECTIVE DATE:

This act shall take effect on the one hundred twentieth day after it shall have become a law.


Text

STATE OF NEW YORK ________________________________________________________________________ 6281 IN SENATE January 9, 2014 ___________
Introduced by Sen. DeFRANCISCO -- 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 the definitions of "clinical peer reviewer" for the purposes of utilization review and external appeal THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Subsection (b) of section 4900 of the insurance law, as amended by chapter 586 of the laws of 1998, is amended to read as follows: (b) "Clinical peer reviewer" means: (1) for purposes of title one of this article: (A) a physician who possesses a current and valid non-restricted license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW; or (B) a health care professional other than a licensed physician who: (i) where applicable, possesses a current and valid non-restricted license, certificate or registration [or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession] ISSUED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW; and (ii) is in the same profession and same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review; and (2) for purposes of title two of this article: (A) a physician who: (i) possesses a current and valid non-restricted license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW; (ii) where applicable, is board certified or board eligible in the same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under appeal;
(iii) has been practicing in such area of specialty for a period of at least five years; and (iv) is knowledgeable about the health care service or treatment under appeal; or (B) a health care professional other than a licensed physician who: (i) where applicable, possesses a current and valid non-restricted license, certificate or registration ISSUED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW; (ii) [where applicable, is credentialed by the national accrediting body appropriate to the profession in the same profession and same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under appeal; (iii)] has been practicing in such area of specialty for a period of at least five years; [(iv)] (III) is knowledgeable about the health care service or treat- ment under appeal; and [(v)] (IV) where applicable to such health care professional's scope of practice, is clinically supported by a physician who possesses a current and valid non-restricted license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW. (3) Nothing [herein] IN THIS ARTICLE shall be construed to change any statutorily-defined scope of practice. S 2. Subdivision 2 of section 4900 of the public health law, as amended by chapter 586 of the laws of 1998, is amended to read as follows: 2. "Clinical peer reviewer" means: (a) for purposes of title one of this article: (i) a physician who possesses a current and valid non-restricted license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW; or (ii) a health care professional other than a licensed physician who: (A) where applicable, possesses a current and valid non-restricted license, certificate or registration [or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession] ISSUED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW; and (B) is in the same profession and same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review; and (b) for purposes of title two of this article: (i) a physician who: (A) possesses a current and valid non-restricted license to practice medicine PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW; (B) where applicable, is board certified or board eligible in the same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under appeal; (C) has been practicing in such area of specialty for a period of at least five years; and (D) is knowledgeable about the health care service or treatment under appeal; or (ii) a health care professional other than a licensed physician who:
(A) where applicable, possesses a current and valid non-restricted license, certificate or registration ISSUED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW; (B) [where applicable, is credentialed by the national accrediting body appropriate to the profession in the same profession and same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under appeal; (C)] has been practicing in such area of specialty for a period of at least five years; [(D)] (C) is knowledgeable about the health care service or treatment under appeal; and [(E)] (D) where applicable to such health care professional's scope of practice, is clinically supported by a physician who possesses a current and valid non-restricted license to practice medicine PURSUANT TO ARTI- CLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW. (c) Nothing [herein] IN THIS ARTICLE shall be construed to change any statutorily-defined scope of practice. S 3. This act shall take effect on the one hundred twentieth day after it shall have become a law.

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