State Codes and Statutes

Statutes > New-york > Isc > Article-48 > 4803

§  4803.  Health  care professional applications and terminations. (a)  (1) An insurer which offers a managed care product shall, upon  request,  make  available  and  disclose  to  health  care  professionals  written  application procedures and minimum qualification  requirements  which  a  health  care  professional  must  meet  in order to be considered by the  insurer for participation in the  in-network  benefits  portion  of  the  insurer's  network  for  the  managed  care  product.  The insurer shall  consult  with  appropriately  qualified  health  care  professionals  in  developing  its  qualification  requirements  for  participation  in the  in-network benefits portion of the insurer's  network  for  the  managed  care  product.  An  insurer  shall  complete  review  of the health care  professional's application to participate in the in-network  portion  of  the insurer's network and, within ninety days of receiving a health care  professional's  completed  application  to  participate in the insurer's  network, will notify the health care professional as to: (A) whether  he  or  she  is credentialed; or (B) whether additional time is necessary to  make a determination in spite of the insurer's best efforts  or  because  of  a  failure  of  a third party to provide necessary documentation, or  non-routine or unusual circumstances require additional time for review.  In such instances where additional time is necessary because of  a  lack  of necessary documentation, an insurer shall make every effort to obtain  such information as soon as possible.    (2)  If  the  completed  application  of  a newly-licensed health care  professional or a health care professional who has recently relocated to  this state from another state and has not previously practiced  in  this  state,  who  joins a group practice of health care professionals each of  whom participates in the in-network portion of an insurer's network,  is  neither  approved  nor declined within ninety days pursuant to paragraph  one of this subsection, such health care professional  shall  be  deemed  "provisionally  credentialed"  and  may  participate  in  the in-network  portion of an insurer's network; provided, however, that a provisionally  credentialed physician may not be designated  as  an  insured's  primary  care  physician  until  such  time  as  the  physician  has  been  fully  credentialed. The network participation for a provisionally credentialed  health care professional shall begin on the day following the  ninetieth  day  of  receipt  of  the completed application and shall last until the  final credentialing determination is made by the insurer. A health  care  professional shall only be eligible for provisional credentialing if the  group  practice  of  health  care  professionals notifies the insurer in  writing that, should the application ultimately be  denied,  the  health  care  professional  or the group practice: (A) shall refund any payments  made  by  the  insurer  for  in-network   services   provided   by   the  provisionally  credentialed  health  care  professional  that exceed any  out-of-network benefits payable under the insured's  contract  with  the  insurer; and (B) shall not pursue reimbursement from the insured, except  to  collect  the copayment or coinsurance that otherwise would have been  payable  had  the  insured  received  services  from   a   health   care  professional  participating  in  the  in-network portion of an insurer's  network. Interest and penalties pursuant to section three  thousand  two  hundred twenty-four-a of this chapter shall not be assessed based on the  denial  of  a  claim  submitted  during  the period when the health care  professional was provisionally  credentialed;  provided,  however,  that  nothing  herein  shall  prevent  an  insurer  from paying a claim from a  health  care  professional  who  is  provisionally   credentialed   upon  submission  of  such  claim.  An insurer shall not deny, after appeal, a  claim for services provided by a provisionally credentialed health  care  professional solely on the ground that the claim was not timely filed.(b)  (1)  An insurer shall not terminate a contract with a health care  professional for participation in the in-network benefits portion of the  insurer's network for a managed care product unless the insurer provides  to the health care professional a written explanation of the reasons for  the  proposed  contract  termination  and an opportunity for a review or  hearing as hereinafter provided. This section shall not apply  in  cases  involving  imminent harm to patient care, a determination of fraud, or a  final  disciplinary  action  by  a  state  licensing  board   or   other  governmental  agency that impairs the health care professional's ability  to practice.    (2) The notice of the proposed contract termination  provided  by  the  insurer to the health care professional shall include:    (i) the reasons for the proposed action;    (ii) notice that the health care professional has the right to request  a  hearing  or  review, at the professional's discretion, before a panel  appointed by the insurer;    (iii) a time limit of not less than thirty days within which a  health  care professional may request a hearing or review; and    (iv)  a  time  limit  for a hearing date which must be held within not  less than thirty days after the date of  receipt  of  a  request  for  a  hearing.    (3) The hearing panel shall be comprised of three persons appointed by  the  insurer. At least one person on such panel shall be a clinical peer  in the same discipline and the same or similar specialty as  the  health  care  professional  under  review. The hearing panel may consist of more  than three persons, provided however that the number of  clinical  peers  on such panel shall constitute one-third or more of the total membership  of the panel.    (4)  The  hearing panel shall render a decision on the proposed action  in a timely manner. Such decision shall  include  reinstatement  of  the  health  care  professional  by  the  insurer,  provisional reinstatement  subject to conditions set forth by the insurer  or  termination  of  the  health  care professional. Such decision shall be provided in writing to  the health care professional.    (5) A decision by  the  hearing  panel  to  terminate  a  health  care  professional  shall  be  effective  not  less than thirty days after the  receipt by the health care professional of the hearing panel's decision;  provided, however, that the provisions of subsection (e) of section four  thousand eight hundred four shall apply to such termination.    (6) In no event shall termination be effective earlier than sixty days  from the receipt of the notice of termination.    (c) Either party to a contract for  participation  in  the  in-network  benefits  portion of an insurer's network for a managed care product may  exercise a right of non-renewal at the expiration of the contract period  set forth therein or, for a contract without a specific expiration date,  on each January first occurring after the contract has  been  in  effect  for  at  least  one  year,  upon  sixty  days notice to the other party;  provided,  however,  that  any  non-renewal  shall  not   constitute   a  termination for purposes of this section.    (d)  An insurer shall develop and implement policies and procedures to  ensure that health care providers participating in  the  the  in-network  benefits  portion of an insurer's network for a managed care product are  regularly informed of information maintained by the insurer to  evaluate  the performance or practice of the health care professional. The insurer  shall consult with health care professionals in developing methodologies  to  collect  and analyze provider profiling data. Insurers shall provide  any such information and profiling data and  analysis  to  these  health  care professionals. Such information, data or analysis shall be providedon a periodic basis appropriate to the nature and amount of data and the  volume  and  scope  of  services  provided.  Any  profiling data used to  evaluate the performance or practice of such a health care  professional  shall  be  measured  against stated criteria and an appropriate group of  health care professionals using similar treatment modalities  serving  a  comparable  patient population. Upon presentation of such information or  data, each such health care professional shall be given the  opportunity  to  discuss  the unique nature of the health care professional's patient  population which may have a bearing on the professional's profile and to  work cooperatively with the insurer to improve performance.    (e) No insurer shall terminate or  refuse  to  renew  a  contract  for  participation in the in-network benefits portion of an insurer's network  for  a  managed care product solely because the health care professional  has (1) advocated on behalf of an insured; (2)  has  filed  a  complaint  against  the  insurer;  (3)  has appealed a decision of the insurer; (4)  provided information or filed a report pursuant  to  section  forty-four  hundred  six-c  of  the public health law; or (5) requested a hearing or  review pursuant to this section.    (f) Except as provided herein, no contract  or  agreement  between  an  insurer  and  a  health  care  professional  for  participation  in  the  in-network benefits portion of an insurer's network for a  managed  care  product  shall  contain  any provision which shall supersede or impair a  health care professional's right to notice of  reasons  for  termination  and the opportunity for a hearing concerning such termination.    (g)  Any  contract  provision  in  violation  of this section shall be  deemed to be void and unenforceable.    (h) For purposes of this section,  "health  care  professional"  shall  mean  a  health  care  professional  licensed,  registered  or certified  pursuant to title eight of the education law.

State Codes and Statutes

Statutes > New-york > Isc > Article-48 > 4803

§  4803.  Health  care professional applications and terminations. (a)  (1) An insurer which offers a managed care product shall, upon  request,  make  available  and  disclose  to  health  care  professionals  written  application procedures and minimum qualification  requirements  which  a  health  care  professional  must  meet  in order to be considered by the  insurer for participation in the  in-network  benefits  portion  of  the  insurer's  network  for  the  managed  care  product.  The insurer shall  consult  with  appropriately  qualified  health  care  professionals  in  developing  its  qualification  requirements  for  participation  in the  in-network benefits portion of the insurer's  network  for  the  managed  care  product.  An  insurer  shall  complete  review  of the health care  professional's application to participate in the in-network  portion  of  the insurer's network and, within ninety days of receiving a health care  professional's  completed  application  to  participate in the insurer's  network, will notify the health care professional as to: (A) whether  he  or  she  is credentialed; or (B) whether additional time is necessary to  make a determination in spite of the insurer's best efforts  or  because  of  a  failure  of  a third party to provide necessary documentation, or  non-routine or unusual circumstances require additional time for review.  In such instances where additional time is necessary because of  a  lack  of necessary documentation, an insurer shall make every effort to obtain  such information as soon as possible.    (2)  If  the  completed  application  of  a newly-licensed health care  professional or a health care professional who has recently relocated to  this state from another state and has not previously practiced  in  this  state,  who  joins a group practice of health care professionals each of  whom participates in the in-network portion of an insurer's network,  is  neither  approved  nor declined within ninety days pursuant to paragraph  one of this subsection, such health care professional  shall  be  deemed  "provisionally  credentialed"  and  may  participate  in  the in-network  portion of an insurer's network; provided, however, that a provisionally  credentialed physician may not be designated  as  an  insured's  primary  care  physician  until  such  time  as  the  physician  has  been  fully  credentialed. The network participation for a provisionally credentialed  health care professional shall begin on the day following the  ninetieth  day  of  receipt  of  the completed application and shall last until the  final credentialing determination is made by the insurer. A health  care  professional shall only be eligible for provisional credentialing if the  group  practice  of  health  care  professionals notifies the insurer in  writing that, should the application ultimately be  denied,  the  health  care  professional  or the group practice: (A) shall refund any payments  made  by  the  insurer  for  in-network   services   provided   by   the  provisionally  credentialed  health  care  professional  that exceed any  out-of-network benefits payable under the insured's  contract  with  the  insurer; and (B) shall not pursue reimbursement from the insured, except  to  collect  the copayment or coinsurance that otherwise would have been  payable  had  the  insured  received  services  from   a   health   care  professional  participating  in  the  in-network portion of an insurer's  network. Interest and penalties pursuant to section three  thousand  two  hundred twenty-four-a of this chapter shall not be assessed based on the  denial  of  a  claim  submitted  during  the period when the health care  professional was provisionally  credentialed;  provided,  however,  that  nothing  herein  shall  prevent  an  insurer  from paying a claim from a  health  care  professional  who  is  provisionally   credentialed   upon  submission  of  such  claim.  An insurer shall not deny, after appeal, a  claim for services provided by a provisionally credentialed health  care  professional solely on the ground that the claim was not timely filed.(b)  (1)  An insurer shall not terminate a contract with a health care  professional for participation in the in-network benefits portion of the  insurer's network for a managed care product unless the insurer provides  to the health care professional a written explanation of the reasons for  the  proposed  contract  termination  and an opportunity for a review or  hearing as hereinafter provided. This section shall not apply  in  cases  involving  imminent harm to patient care, a determination of fraud, or a  final  disciplinary  action  by  a  state  licensing  board   or   other  governmental  agency that impairs the health care professional's ability  to practice.    (2) The notice of the proposed contract termination  provided  by  the  insurer to the health care professional shall include:    (i) the reasons for the proposed action;    (ii) notice that the health care professional has the right to request  a  hearing  or  review, at the professional's discretion, before a panel  appointed by the insurer;    (iii) a time limit of not less than thirty days within which a  health  care professional may request a hearing or review; and    (iv)  a  time  limit  for a hearing date which must be held within not  less than thirty days after the date of  receipt  of  a  request  for  a  hearing.    (3) The hearing panel shall be comprised of three persons appointed by  the  insurer. At least one person on such panel shall be a clinical peer  in the same discipline and the same or similar specialty as  the  health  care  professional  under  review. The hearing panel may consist of more  than three persons, provided however that the number of  clinical  peers  on such panel shall constitute one-third or more of the total membership  of the panel.    (4)  The  hearing panel shall render a decision on the proposed action  in a timely manner. Such decision shall  include  reinstatement  of  the  health  care  professional  by  the  insurer,  provisional reinstatement  subject to conditions set forth by the insurer  or  termination  of  the  health  care professional. Such decision shall be provided in writing to  the health care professional.    (5) A decision by  the  hearing  panel  to  terminate  a  health  care  professional  shall  be  effective  not  less than thirty days after the  receipt by the health care professional of the hearing panel's decision;  provided, however, that the provisions of subsection (e) of section four  thousand eight hundred four shall apply to such termination.    (6) In no event shall termination be effective earlier than sixty days  from the receipt of the notice of termination.    (c) Either party to a contract for  participation  in  the  in-network  benefits  portion of an insurer's network for a managed care product may  exercise a right of non-renewal at the expiration of the contract period  set forth therein or, for a contract without a specific expiration date,  on each January first occurring after the contract has  been  in  effect  for  at  least  one  year,  upon  sixty  days notice to the other party;  provided,  however,  that  any  non-renewal  shall  not   constitute   a  termination for purposes of this section.    (d)  An insurer shall develop and implement policies and procedures to  ensure that health care providers participating in  the  the  in-network  benefits  portion of an insurer's network for a managed care product are  regularly informed of information maintained by the insurer to  evaluate  the performance or practice of the health care professional. The insurer  shall consult with health care professionals in developing methodologies  to  collect  and analyze provider profiling data. Insurers shall provide  any such information and profiling data and  analysis  to  these  health  care professionals. Such information, data or analysis shall be providedon a periodic basis appropriate to the nature and amount of data and the  volume  and  scope  of  services  provided.  Any  profiling data used to  evaluate the performance or practice of such a health care  professional  shall  be  measured  against stated criteria and an appropriate group of  health care professionals using similar treatment modalities  serving  a  comparable  patient population. Upon presentation of such information or  data, each such health care professional shall be given the  opportunity  to  discuss  the unique nature of the health care professional's patient  population which may have a bearing on the professional's profile and to  work cooperatively with the insurer to improve performance.    (e) No insurer shall terminate or  refuse  to  renew  a  contract  for  participation in the in-network benefits portion of an insurer's network  for  a  managed care product solely because the health care professional  has (1) advocated on behalf of an insured; (2)  has  filed  a  complaint  against  the  insurer;  (3)  has appealed a decision of the insurer; (4)  provided information or filed a report pursuant  to  section  forty-four  hundred  six-c  of  the public health law; or (5) requested a hearing or  review pursuant to this section.    (f) Except as provided herein, no contract  or  agreement  between  an  insurer  and  a  health  care  professional  for  participation  in  the  in-network benefits portion of an insurer's network for a  managed  care  product  shall  contain  any provision which shall supersede or impair a  health care professional's right to notice of  reasons  for  termination  and the opportunity for a hearing concerning such termination.    (g)  Any  contract  provision  in  violation  of this section shall be  deemed to be void and unenforceable.    (h) For purposes of this section,  "health  care  professional"  shall  mean  a  health  care  professional  licensed,  registered  or certified  pursuant to title eight of the education law.

State Codes and Statutes

State Codes and Statutes

Statutes > New-york > Isc > Article-48 > 4803

§  4803.  Health  care professional applications and terminations. (a)  (1) An insurer which offers a managed care product shall, upon  request,  make  available  and  disclose  to  health  care  professionals  written  application procedures and minimum qualification  requirements  which  a  health  care  professional  must  meet  in order to be considered by the  insurer for participation in the  in-network  benefits  portion  of  the  insurer's  network  for  the  managed  care  product.  The insurer shall  consult  with  appropriately  qualified  health  care  professionals  in  developing  its  qualification  requirements  for  participation  in the  in-network benefits portion of the insurer's  network  for  the  managed  care  product.  An  insurer  shall  complete  review  of the health care  professional's application to participate in the in-network  portion  of  the insurer's network and, within ninety days of receiving a health care  professional's  completed  application  to  participate in the insurer's  network, will notify the health care professional as to: (A) whether  he  or  she  is credentialed; or (B) whether additional time is necessary to  make a determination in spite of the insurer's best efforts  or  because  of  a  failure  of  a third party to provide necessary documentation, or  non-routine or unusual circumstances require additional time for review.  In such instances where additional time is necessary because of  a  lack  of necessary documentation, an insurer shall make every effort to obtain  such information as soon as possible.    (2)  If  the  completed  application  of  a newly-licensed health care  professional or a health care professional who has recently relocated to  this state from another state and has not previously practiced  in  this  state,  who  joins a group practice of health care professionals each of  whom participates in the in-network portion of an insurer's network,  is  neither  approved  nor declined within ninety days pursuant to paragraph  one of this subsection, such health care professional  shall  be  deemed  "provisionally  credentialed"  and  may  participate  in  the in-network  portion of an insurer's network; provided, however, that a provisionally  credentialed physician may not be designated  as  an  insured's  primary  care  physician  until  such  time  as  the  physician  has  been  fully  credentialed. The network participation for a provisionally credentialed  health care professional shall begin on the day following the  ninetieth  day  of  receipt  of  the completed application and shall last until the  final credentialing determination is made by the insurer. A health  care  professional shall only be eligible for provisional credentialing if the  group  practice  of  health  care  professionals notifies the insurer in  writing that, should the application ultimately be  denied,  the  health  care  professional  or the group practice: (A) shall refund any payments  made  by  the  insurer  for  in-network   services   provided   by   the  provisionally  credentialed  health  care  professional  that exceed any  out-of-network benefits payable under the insured's  contract  with  the  insurer; and (B) shall not pursue reimbursement from the insured, except  to  collect  the copayment or coinsurance that otherwise would have been  payable  had  the  insured  received  services  from   a   health   care  professional  participating  in  the  in-network portion of an insurer's  network. Interest and penalties pursuant to section three  thousand  two  hundred twenty-four-a of this chapter shall not be assessed based on the  denial  of  a  claim  submitted  during  the period when the health care  professional was provisionally  credentialed;  provided,  however,  that  nothing  herein  shall  prevent  an  insurer  from paying a claim from a  health  care  professional  who  is  provisionally   credentialed   upon  submission  of  such  claim.  An insurer shall not deny, after appeal, a  claim for services provided by a provisionally credentialed health  care  professional solely on the ground that the claim was not timely filed.(b)  (1)  An insurer shall not terminate a contract with a health care  professional for participation in the in-network benefits portion of the  insurer's network for a managed care product unless the insurer provides  to the health care professional a written explanation of the reasons for  the  proposed  contract  termination  and an opportunity for a review or  hearing as hereinafter provided. This section shall not apply  in  cases  involving  imminent harm to patient care, a determination of fraud, or a  final  disciplinary  action  by  a  state  licensing  board   or   other  governmental  agency that impairs the health care professional's ability  to practice.    (2) The notice of the proposed contract termination  provided  by  the  insurer to the health care professional shall include:    (i) the reasons for the proposed action;    (ii) notice that the health care professional has the right to request  a  hearing  or  review, at the professional's discretion, before a panel  appointed by the insurer;    (iii) a time limit of not less than thirty days within which a  health  care professional may request a hearing or review; and    (iv)  a  time  limit  for a hearing date which must be held within not  less than thirty days after the date of  receipt  of  a  request  for  a  hearing.    (3) The hearing panel shall be comprised of three persons appointed by  the  insurer. At least one person on such panel shall be a clinical peer  in the same discipline and the same or similar specialty as  the  health  care  professional  under  review. The hearing panel may consist of more  than three persons, provided however that the number of  clinical  peers  on such panel shall constitute one-third or more of the total membership  of the panel.    (4)  The  hearing panel shall render a decision on the proposed action  in a timely manner. Such decision shall  include  reinstatement  of  the  health  care  professional  by  the  insurer,  provisional reinstatement  subject to conditions set forth by the insurer  or  termination  of  the  health  care professional. Such decision shall be provided in writing to  the health care professional.    (5) A decision by  the  hearing  panel  to  terminate  a  health  care  professional  shall  be  effective  not  less than thirty days after the  receipt by the health care professional of the hearing panel's decision;  provided, however, that the provisions of subsection (e) of section four  thousand eight hundred four shall apply to such termination.    (6) In no event shall termination be effective earlier than sixty days  from the receipt of the notice of termination.    (c) Either party to a contract for  participation  in  the  in-network  benefits  portion of an insurer's network for a managed care product may  exercise a right of non-renewal at the expiration of the contract period  set forth therein or, for a contract without a specific expiration date,  on each January first occurring after the contract has  been  in  effect  for  at  least  one  year,  upon  sixty  days notice to the other party;  provided,  however,  that  any  non-renewal  shall  not   constitute   a  termination for purposes of this section.    (d)  An insurer shall develop and implement policies and procedures to  ensure that health care providers participating in  the  the  in-network  benefits  portion of an insurer's network for a managed care product are  regularly informed of information maintained by the insurer to  evaluate  the performance or practice of the health care professional. The insurer  shall consult with health care professionals in developing methodologies  to  collect  and analyze provider profiling data. Insurers shall provide  any such information and profiling data and  analysis  to  these  health  care professionals. Such information, data or analysis shall be providedon a periodic basis appropriate to the nature and amount of data and the  volume  and  scope  of  services  provided.  Any  profiling data used to  evaluate the performance or practice of such a health care  professional  shall  be  measured  against stated criteria and an appropriate group of  health care professionals using similar treatment modalities  serving  a  comparable  patient population. Upon presentation of such information or  data, each such health care professional shall be given the  opportunity  to  discuss  the unique nature of the health care professional's patient  population which may have a bearing on the professional's profile and to  work cooperatively with the insurer to improve performance.    (e) No insurer shall terminate or  refuse  to  renew  a  contract  for  participation in the in-network benefits portion of an insurer's network  for  a  managed care product solely because the health care professional  has (1) advocated on behalf of an insured; (2)  has  filed  a  complaint  against  the  insurer;  (3)  has appealed a decision of the insurer; (4)  provided information or filed a report pursuant  to  section  forty-four  hundred  six-c  of  the public health law; or (5) requested a hearing or  review pursuant to this section.    (f) Except as provided herein, no contract  or  agreement  between  an  insurer  and  a  health  care  professional  for  participation  in  the  in-network benefits portion of an insurer's network for a  managed  care  product  shall  contain  any provision which shall supersede or impair a  health care professional's right to notice of  reasons  for  termination  and the opportunity for a hearing concerning such termination.    (g)  Any  contract  provision  in  violation  of this section shall be  deemed to be void and unenforceable.    (h) For purposes of this section,  "health  care  professional"  shall  mean  a  health  care  professional  licensed,  registered  or certified  pursuant to title eight of the education law.

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