Regulates the scope, manner and performance of review of claims by utilization review agents

1 Co-sponsor

• William J. Larkin Jr.

BILL NUMBER:S5834

Title of bill

An act to amend the public health law and the insurance law, in relation to approvals by a utilization review agent

Purpose

This bill amends the public health and insurance laws related to utilization review and external appeals.

Summary of provisions

Section 1 amends Subdivision 2 of § 4903 of the public health law to require written notification to the enrollee's health care provider be transmitted electronically, to the extent practicable, in a manner and form agreed to by the parties.

Section 2 amends Subdivision 2 of § 4914 of the public health law to extend the external appeal provider timeframe from 45 days to 60 days.

Sections 3 and 4 make the same changes as Sections 1 and 2 of the bill in the insurance law.

Section 5 provides for an effective date of 7/1/14.

Justification

This bill is intended to address certain health plan practices that result in unfair and unilateral reductions of payments and claims denials. This bill strikes a balance, as it preserves all health plan rights to review medical necessity, utilization of services, and claims payment processing but in a manner that provides fairness to providers and a remedy when certain utilization reviews are misapplied by health plans.

New York law requires a utilization review agent to provide notice of a claim determination to the enrollee or the enrollee's designee and the enrollee's health care provider by telephone and in writing within three business days of receipt of the necessary information for preauthori- zation. Sections 1 and 3 of the bill require such written notice to be transmitted electronically, to the extent practicable. Such electronic transmissions would decrease the administrative cost of health care services and provide a record of utilization review agents' compliance with this requirement.

Sections 2 and 4 of the bill provide a longer timeframe for providers to submit external appeals. Legislation was enacted in 2011 that codified New York's external appeal law with the standards in the Patient Protection and Affordable Care Act. The timeframe for patients or patients' designees to submit an appeal to the Department of Financial Services was extended from 45 days to four months. Providers' timeframe for an external appeal remains at 45 days and this legislation provides a greater balance by lengthening the providers' timeframe for an external appeal to 60 days.

Legislative history

New bill.

Fiscal implications

None.

Effective date

This act shall take effect on July 1, 2014.