§ 4803 — Health care professional applications and terminations

New York § 4803

• Jurisdiction: New York
• Law ISC: Insurance
• Art. 48: Managed Care Health Insurance Contracts

Text

§ 4803. Health care professional applications and terminations. (a)\n(1) An insurer which offers a managed care product shall, upon request,\nmake available and disclose to health care professionals written\napplication procedures and minimum qualification requirements which a\nhealth care professional must meet in order to be considered by the\ninsurer for participation in the in-network benefits portion of the\ninsurer's network for the managed care product. The insurer shall\nconsult with appropriately qualified health care professionals in\ndeveloping its qualification requirements for participation in the\nin-network benefits portion of the insurer's network for the managed\ncare product. An insurer shall complete review of the health care\nprofessional's application to participate in the in-network portion of\nthe insurer's network and, within sixty days of receiving a health care\nprofessional's completed application to participate in the insurer's\nnetwork, will notify the health care professional as to: (A) whether he\nor she is credentialed; or (B) whether additional time is necessary to\nmake a determination because of a failure of a third party to provide\nnecessary documentation. In such instances where additional time is\nnecessary because of a lack of necessary documentation, an insurer shall\nmake every effort to obtain such information as soon as possible and\nshall make a final determination within twenty-one days of receiving the\nnecessary documentation.\n (2) If the completed application of a newly-licensed health care\nprofessional or a health care professional who has recently relocated to\nthis state from another state and has not previously practiced in this\nstate, who joins a group practice of health care professionals each of\nwhom participates in the in-network portion of an insurer's network, is\nneither approved nor declined within sixty days of submission of a\ncompleted application pursuant to paragraph one of this subsection, such\nhealth care professional shall be deemed "provisionally credentialed"\nand may participate in the in-network portion of an insurer's network;\nprovided, however, that a provisionally credentialed physician may not\nbe designated as an insured's primary care physician until such time as\nthe physician has been fully credentialed. The network participation for\na provisionally credentialed health care professional shall begin on the\nday following the sixtieth day of receipt of the completed application\nand shall last until the final credentialing determination is made by\nthe insurer. A health care professional shall only be eligible for\nprovisional credentialing if the group practice of health care\nprofessionals notifies the insurer in writing that, should the\napplication ultimately be denied, the health care professional or the\ngroup practice: (A) shall refund any payments made by the insurer for\nin-network services provided by the provisionally credentialed health\ncare professional that exceed any out-of-network benefits payable under\nthe insured's contract with the insurer; and (B) shall not pursue\nreimbursement from the insured, except to collect the copayment or\ncoinsurance that otherwise would have been payable had the insured\nreceived services from a health care professional participating in the\nin-network portion of an insurer's network. Interest and penalties\npursuant to section three thousand two hundred twenty-four-a of this\nchapter shall not be assessed based on the denial of a claim submitted\nduring the period when the health care professional was provisionally\ncredentialed; provided, however, that nothing herein shall prevent an\ninsurer from paying a claim from a health care professional who is\nprovisionally credentialed upon submission of such claim. An insurer\nshall not deny, after appeal, a claim for services provided by a\nprovisionally credentialed health care professional solely on the ground\nthat the claim was not timely filed.\n (3) A newly-licensed physician, a physician who has recently relocated\nto this state from another state and has not previously practiced in\nthis state, or a physician who has changed his or her corporate\nrelationship such that it results in the issuance of a new tax\nidentification number under which such physician's services are billed\nfor and who previously had a participation contract with the insurer\nimmediately prior to the event that changed his or her corporate\nrelationship, who becomes employed by a general hospital or diagnostic\nand treatment center licensed pursuant to article twenty-eight of the\npublic health law, or a facility licensed under article sixteen, article\nthirty-one or article thirty-two of the mental hygiene law which has a\nparticipating provider contract with an insurer, and whose other\nemployed physicians participate in the in-network portion of an\ninsurer's network, shall be deemed "provisionally credentialed" and may\nparticipate in the in-network portion of an insurer's network during\nthis time period upon: (A) the insurer's receipt of the hospital and\nphysician's completed sections of the insurer's credentialing\napplication; and (B) the insurer being notified in writing that the\nhealth care professional has been granted hospital privileges pursuant\nto the requirements of section twenty-eight hundred five-k of the public\nhealth law. However, a provisionally credentialed physician shall not be\ndesignated as an insured's primary care physician until such time as the\nphysician has been fully credentialed by the insurer. Notwithstanding\nany other provision of law, an insurer shall not be required to make any\npayments to the licensed general hospital, the licensed diagnostic and\ntreatment center or a facility licensed under article sixteen, article\nthirty-one or article thirty-two of the mental hygiene law for the\nservice provided by a provisionally credentialed physician, until and\nunless the physician is fully credentialed by the insurer, provided,\nhowever, that upon being fully credentialed, the licensed general\nhospital, the licensed diagnostic and treatment center or a facility\nlicensed under article sixteen, article thirty-one or article thirty-two\nof the mental hygiene law shall be paid for all services provided by the\nphysician for up to sixty days after submission of the completed\napplication that the credentialed physician provided to the insurer's\nsubscribers or members from the date the physician fully met the\nrequirements to be provisionally credentialed pursuant to this\nparagraph. Should the application ultimately be denied by the insurer,\nthe insurer shall not be liable for any payment to the licensed general\nhospital, the licensed diagnostic and treatment center or a facility\nlicensed under article sixteen, article thirty-one or article thirty-two\nof the mental hygiene law for the services provided by the provisionally\ncredentialed health care professional that exceeds any out-of-network\nbenefits payable under the insured's contract with the insurer; and the\nlicensed general hospital, the licensed diagnostic and treatment center\nor a facility licensed under article sixteen, article thirty-one or\narticle thirty-two of the mental hygiene law shall not pursue\nreimbursement from the insured, except to collect the copayment or\ncoinsurance or deductible amount that otherwise would have been payable\nhad the insured received services from a health care professional\nparticipating in the in-network portion of an insurer's network.\n (b) (1) An insurer shall not terminate a contract with a health care\nprofessional for participation in the in-network benefits portion of the\ninsurer's network for a managed care product unless the insurer provides\nto the health care professional a written explanation of the reasons for\nthe proposed contract termination and an opportunity for a review or\nhearing as hereinafter provided. This section shall not apply in cases\ninvolving imminent harm to patient care, a determination of fraud, or a\nfinal disciplinary action by a state licensing board or other\ngovernmental agency that impairs the health care professional's ability\nto practice.\n (2) The notice of the proposed contract termination provided by the\ninsurer to the health care professional shall include:\n (i) the reasons for the proposed action;\n (ii) notice that the health care professional has the right to request\na hearing or review, at the professional's discretion, before a panel\nappointed by the insurer;\n (iii) a time limit of not less than thirty days within which a health\ncare professional may request a hearing or review; and\n (iv) a time limit for a hearing date which must be held within not\nless than thirty days after the date of receipt of a request for a\nhearing.\n (3) The hearing panel shall be comprised of three persons appointed by\nthe insurer. At least one person on such panel shall be a clinical peer\nin the same discipline and the same or similar specialty as the health\ncare professional under review. The hearing panel may consist of more\nthan three persons, provided however that the number of clinical peers\non such panel shall constitute one-third or more of the total membership\nof the panel.\n (4) The hearing panel shall render a decision on the proposed action\nin a timely manner. Such decision shall include reinstatement of the\nhealth care professional by the insurer, provisional reinstatement\nsubject to conditions set forth by the insurer or termination of the\nhealth care professional. Such decision shall be provided in writing to\nthe health care professional.\n (5) A decision by the hearing panel to terminate a health care\nprofessional shall be effective not less than thirty days after the\nreceipt by the health care professional of the hearing panel's decision;\nprovided, however, that the provisions of subsection (e) of section four\nthousand eight hundred four shall apply to such termination.\n (6) In no event shall termination be effective earlier than sixty days\nfrom the receipt of the notice of termination.\n (c) Either party to a contract for participation in the in-network\nbenefits portion of an insurer's network for a managed care product may\nexercise a right of non-renewal at the expiration of the contract period\nset forth therein or, for a contract without a specific expiration date,\non each January first occurring after the contract has been in effect\nfor at least one year, upon sixty days notice to the other party;\nprovided, however, that any non-renewal shall not constitute a\ntermination for purposes of this section.\n (d) An insurer shall develop and implement policies and procedures to\nensure that health care providers participating in the the in-network\nbenefits portion of an insurer's network for a managed care product are\nregularly informed of information maintained by the insurer to evaluate\nthe performance or practice of the health care professional. The insurer\nshall consult with health care professionals in developing methodologies\nto collect and analyze provider profiling data. Insurers shall provide\nany such information and profiling data and analysis to these health\ncare professionals. Such information, data or analysis shall be provided\non a periodic basis appropriate to the nature and amount of data and the\nvolume and scope of services provided. Any profiling data used to\nevaluate the performance or practice of such a health care professional\nshall be measured against stated criteria and an appropriate group of\nhealth care professionals using similar treatment modalities serving a\ncomparable patient population. Upon presentation of such information or\ndata, each such health care professional shall be given the opportunity\nto discuss the unique nature of the health care professional's patient\npopulation which may have a bearing on the professional's profile and to\nwork cooperatively with the insurer to improve performance.\n (e) No insurer shall terminate or refuse to renew a contract for\nparticipation in the in-network benefits portion of an insurer's network\nfor a managed care product solely because the health care professional\nhas (1) advocated on behalf of an insured; (2) has filed a complaint\nagainst the insurer; (3) has appealed a decision of the insurer; (4)\nprovided information or filed a report pursuant to section forty-four\nhundred six-c of the public health law; or (5) requested a hearing or\nreview pursuant to this section.\n (f) Except as provided herein, no contract or agreement between an\ninsurer and a health care professional for participation in the\nin-network benefits portion of an insurer's network for a managed care\nproduct shall contain any provision which shall supersede or impair a\nhealth care professional's right to notice of reasons for termination\nand the opportunity for a hearing concerning such termination.\n (g) Any contract provision in violation of this section shall be\ndeemed to be void and unenforceable.\n (h) For purposes of this section, "health care professional" shall\nmean a health care professional licensed, registered or certified\npursuant to title eight of the education law.\n