§ 3224-B — Rules relating to the processing of health claims and overpayments to physicians

§ 3224-b. Rules relating to the processing of health claims and\noverpayments to physicians. (a) Processing of health care claims. This\nsubsection is intended to provide uniformity and consistency in the\nreporting of medical services and procedures as they relate to the\nprocessing of health care claims and is not intended to dictate\nreimbursement policy.\n (1) For purposes of this section, a "health plan" shall be defined as\nan insurer that is licensed to write accident and health insurance, or\nthat is licensed pursuant to article forty-three of this chapter or is\ncertified pursuant to article forty-four of the public health law.\n (2) Subject to the provisions of paragraph three of this subsection, a\nhealth plan shall accept and initiate the processing of all health care\nclaims submitted by a physician pursuant to and consistent with the\ncurrent version of the American medical association's current procedural\nterminology (CPT) codes, reporting guidelines and conventions and the\ncenters for medicare and medicaid services healthcare common procedure\ncoding system (HCPCS).\n (3) Nothing in this section shall preclude a health plan from\ndetermining that any such claim is not eligible for payment, in full or\nin part, based on a determination that: (i) the claim is not complete as\ndefined by 11 NYCRR 217; (ii) the service provided is not a covered\nbenefit under the contract or agreement, including but not limited to, a\ndetermination that such service is not medically necessary or is\nexperimental or investigational; (iii) the insured did not obtain a\nreferral, pre-certification or satisfy any other condition precedent to\nreceive covered benefits from the physician; (iv) the covered benefit\nexceeds the benefit limits of the contract or agreement; (v) the person\nis not eligible for coverage or is otherwise not compliant with the\nterms and conditions of his or her contract; (vi) another insurer,\ncorporation or organization is liable for all or part of the claim; or\n(vii) the plan has a reasonable suspicion of fraud or abuse. In\naddition, nothing in this section shall be deemed to require a health\nplan to pay or reimburse a claim, in full or in part, or dictate the\namount of a claim to be paid by a health plan to a physician.\n (4) Every health plan shall publish on its provider website and in its\nprovider newsletter the name of the commercially available claims\nediting software product that the health plan utilizes and any\nsignificant edits, as determined by the health plan, added to the claims\nsoftware product after the effective date of this section, which are\nmade at the request of the health plan. The health plan shall also\nprovide such information upon the written request of a physician who is\na participating physician in the health plan's provider network.\n (b) Overpayments to health care providers. (1) Other than recovery for\nduplicate payments, a health plan shall provide thirty days written\nnotice to health care providers before engaging in additional\noverpayment recovery efforts seeking recovery of the overpayment of\nclaims to such health care providers. Such notice shall state the\npatient name, service date, payment amount, proposed adjustment, and a\nreasonably specific explanation of the proposed adjustment.\n (2) A health plan shall provide a health care provider with the\nopportunity to challenge an overpayment recovery, including the sharing\nof claims information, and shall establish written policies and\nprocedures for health care providers to follow to challenge an\noverpayment recovery. Such challenge shall set forth the specific\ngrounds on which the provider is challenging the overpayment recovery.\n (3) A health plan shall not initiate overpayment recovery efforts more\nthan twenty-four months after the original payment was received by a\nhealth care provider. However, no such time limit shall apply to\noverpayment recovery efforts that are: (i) based on a reasonable belief\nof fraud or other intentional misconduct, or abusive billing, (ii)\nrequired by, or initiated at the request of, a self-insured plan, or\n(iii) required or authorized by a state or federal government program or\ncoverage that is provided by this state or a municipality thereof to its\nrespective employees, retirees or members. Notwithstanding the\naforementioned time limitations, in the event that a health care\nprovider asserts that a health plan has underpaid a claim or claims, the\nhealth plan may defend or set off such assertion of underpayment based\non overpayments going back in time as far as the claimed underpayment.\nFor purposes of this paragraph, "abusive billing" shall be defined as a\nbilling practice which results in the submission of claims that are not\nconsistent with sound fiscal, business, or medical practices and at such\nfrequency and for such a period of time as to reflect a consistent\ncourse of conduct.\n (4) For the purposes of this subsection the term "health care\nprovider" shall mean an entity licensed or certified pursuant to article\ntwenty-eight, thirty-six or forty of the public health law, a facility\nlicensed pursuant to article nineteen, thirty-one or thirty-two of the\nmental hygiene law, or a health care professional licensed, registered\nor certified pursuant to title eight of the education law.\n (5) Nothing in this section shall be deemed to limit a health plan's\nright to pursue recovery of overpayments that occurred prior to the\neffective date of this section where the health plan has provided the\nhealth care provider with notice of such recovery efforts prior to the\neffective date of this section.\n