§ 4406-D — Health care professional applications and terminations

§ 4406-d. Health care professional applications and terminations. 1.\n(a) A health care plan shall, upon request, make available and disclose\nto health care professionals written application procedures and minimum\nqualification requirements which a health care professional must meet in\norder to be considered by the health care plan. The plan shall consult\nwith appropriately qualified health care professionals in developing its\nqualification requirements. A health care plan shall complete review of\nthe health care professional's application to participate in the\nin-network portion of the health care plan's network and shall, within\nsixty days of receiving a health care professional's completed\napplication to participate in the health care plan's network, notify the\nhealth care professional as to: (i) whether he or she is credentialed;\nor (ii) whether additional time is necessary to make a determination\nbecause of a failure of a third party to provide necessary\ndocumentation. In such instances where additional time is necessary\nbecause of a lack of necessary documentation, a health plan shall make\nevery effort to obtain such information as soon as possible and shall\nmake a final determination within twenty-one days of receiving the\nnecessary documentation.\n (b) 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 a health care plan's\nnetwork, is neither approved nor declined within sixty days of\nsubmission of a completed application pursuant to paragraph (a) of this\nsubdivision, the health care professional shall be deemed "provisionally\ncredentialed" and may participate in the in-network portion of the\nhealth care plan's network; provided, however, that a provisionally\ncredentialed physician may not be designated as an enrollee's primary\ncare physician until such time as the physician has been fully\ncredentialed. The network participation for a provisionally credentialed\nhealth care professional shall begin on the day following the sixtieth\nday of receipt of the completed application and shall last until the\nfinal credentialing determination is made by the health care plan. A\nhealth care professional shall only be eligible for provisional\ncredentialing if the group practice of health care professionals\nnotifies the health care plan in writing that, should the application\nultimately be denied, the health care professional or the group\npractice: (i) shall refund any payments made by the health care plan for\nin-network services provided by the provisionally credentialed health\ncare professional that exceed any out-of-network benefits payable under\nthe enrollee's contract with the health care plan; and (ii) shall not\npursue reimbursement from the enrollee, except to collect the copayment\nthat otherwise would have been payable had the enrollee received\nservices from a health care professional participating in the in-network\nportion of a health care plan's network. Interest and penalties pursuant\nto section three thousand two hundred twenty-four-a of the insurance law\nshall not be assessed based on the denial of a claim submitted during\nthe period when the health care professional was provisionally\ncredentialed; provided, however, that nothing herein shall prevent a\nhealth care plan from paying a claim from a health care professional who\nis provisionally credentialed upon submission of such claim. A health\ncare plan shall not deny, after appeal, a claim for services provided by\na provisionally credentialed health care professional solely on the\nground that the claim was not timely filed.\n (c) 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 health care\nplan immediately 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 this\nchapter, 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 a health care plan, and whose other\nemployed physicians participate in the in-network portion of a health\ncare plan's network, shall be deemed "provisionally credentialed" and\nmay participate in the in-network portion of a health care plan's\nnetwork during this time period upon: (i) the health care plan's receipt\nof the hospital and physician's completed sections of the insurer's\ncredentialing application; and (ii) the health care plan being notified\nin writing that the health care professional has been granted hospital\nprivileges pursuant to the requirements of section twenty-eight hundred\nfive-k of this chapter. However, a provisionally credentialed physician\nshall not be designated as an enrollee's primary care physician until\nsuch time as the physician has been fully credentialed by the health\ncare plan. Notwithstanding any other provision of law, a health care\nplan shall not be required to make any payments 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 service provided by a provisionally\ncredentialed physician, until and unless the physician is fully\ncredentialed by the health care plan, provided, however, that upon being\nfully credentialed, the licensed general hospital, the licensed\ndiagnostic and treatment center or a facility licensed under article\nsixteen, article thirty-one or article thirty-two of the mental hygiene\nlaw shall be paid for all services provided by the physician for up to\nsixty days after submission of the completed application that the\ncredentialed physician provided to the health care plan's insureds from\nthe date the physician fully met the requirements to be provisionally\ncredentialed pursuant to this paragraph. Should the application\nultimately be denied by the health care plan, the health care plan shall\nnot be liable for any payment to the licensed general hospital, the\nlicensed diagnostic and treatment center or a facility licensed under\narticle sixteen, article thirty-one or article thirty-two of the mental\nhygiene law for the services provided by the provisionally credentialed\nhealth care professional; and the licensed general hospital, the\nlicensed diagnostic and treatment center or a facility licensed under\narticle sixteen, article thirty-one or article thirty-two of the mental\nhygiene law shall not pursue reimbursement from the insured, except to\ncollect the copayment or coinsurance or deductible amount that otherwise\nwould have been payable had the insured received services from a health\ncare professional participating in the in-network portion of a health\ncare plan's network.\n 2. (a) A health care plan shall not terminate a contract with a health\ncare professional unless the health care plan provides to the health\ncare professional a written explanation of the reasons for the proposed\ncontract termination and an opportunity for a review or hearing as\nhereinafter provided. This section shall not apply in cases involving\nimminent harm to patient care, a determination of fraud, or a final\ndisciplinary action by a state licensing board or other governmental\nagency that impairs the health care professional's ability to practice.\n (b) The notice of the proposed contract termination provided by the\nhealth care plan 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 health care plan;\n (iii) a time limit of not less than thirty days within which a health\ncare professional may request a hearing; and\n (iv) a time limit for a hearing date which must be held within thirty\ndays after the date of receipt of a request for a hearing.\n (c) The hearing panel shall be comprised of three persons appointed by\nthe health care plan. At least one person on such panel shall be a\nclinical peer in the same discipline and the same or similar specialty\nas the health care professional under review. The hearing panel may\nconsist of more than three persons, provided however that the number of\nclinical peers on such panel shall constitute one-third or more of the\ntotal membership of the panel.\n (d) 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 health care plan, provisional\nreinstatement subject to conditions set forth by the health care plan or\ntermination of the health care professional. Such decision shall be\nprovided in writing to the health care professional.\n (e) 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 paragraph (e) of subdivision\nsix of section four thousand four hundred three of this article shall\napply to such termination.\n (f) In no event shall termination be effective earlier than sixty days\nfrom the receipt of the notice of termination.\n 3. Either party to a contract may exercise a right of non-renewal at\nthe expiration of the contract period set forth therein or, for a\ncontract without a specific expiration date, on each January first\noccurring after the contract has been in effect for at least one year,\nupon sixty days notice to the other party; provided, however, that any\nnon-renewal shall not constitute a termination for purposes of this\nsection.\n 4. A health care plan shall develop and implement policies and\nprocedures to ensure that health care professionals are regularly\ninformed of information maintained by the health care plan to evaluate\nthe performance or practice of the health care professional. The health\ncare plan shall consult with health care professionals in developing\nmethodologies to collect and analyze health care professional profiling\ndata. Health care plans shall provide any such information and profiling\ndata and analysis to health care professionals. Such information, data\nor analysis shall be provided on a periodic basis appropriate to the\nnature and amount of data and the volume and scope of services provided.\nAny profiling data used to evaluate the performance or practice of a\nhealth care professional shall be measured against stated criteria and\nan appropriate group of health care professionals using similar\ntreatment modalities serving a comparable patient population. Upon\npresentation of such information or data, each health care professional\nshall be given the opportunity to discuss the unique nature of the\nhealth care professional's patient population which may have a bearing\non the health care professional's profile and to work cooperatively with\nthe health care plan to improve performance.\n 5. No health care plan shall terminate a contract or employment, or\nrefuse to renew a contract, solely because a health care provider has:\n (a) advocated on behalf of an enrollee;\n (b) filed a complaint against the health care plan;\n (c) appealed a decision of the health care plan;\n (d) provided information or filed a report pursuant to section\nforty-four hundred six-c of this article; or\n (e) requested a hearing or review pursuant to this section.\n 6. Except as provided herein, no contract or agreement between a\nhealth care plan and a health care professional shall contain any\nprovision which shall supersede or impair a health care professional's\nright to notice of reasons for termination and the opportunity for a\nhearing or review concerning such termination.\n 7. Any contract provision in violation of this section shall be deemed\nto be void and unenforceable.\n 8. For purposes of this section, "health care plan" shall mean a\nhealth maintenance organization licensed pursuant to article forty-three\nof the insurance law or certified pursuant to this article or an\nindependent practice association certified or recognized pursuant to\nthis article.\n 9. For purposes of this section, "health care professional" shall mean\na health care professional licensed, registered or certified pursuant to\ntitle eight of the education law.\n