Shortens time frames during which an insurer has to determine whether a pre-authorization request is medically necessary

Title of bill

An act to amend the insurance law and the public health law, in relation to shortening time frames during which an insurer has to determine whether a pre-authorization request is medically necessary

Purpose

To shorten time frames during which an insurer has to determine whether a pre-authorization request is medically necessary.

Summary of provisions

Section 1. Amends Subsection (b) of section 4903 of the insurance law to require that a utilization review agent shall make a determination involving health care services which require pre-authorization and provide notice of the determination to the insured by telephone and in writing within three days, rather than three business days, of receipt of the necessary information.

Section 1-a. Ensures the above changes are retained in law upon the expiration of the existing subsection (b) on March 31, 2015.

Section 2. Amends subdivision 2 of section 4903 of the public health law to require that a utilization review agent shall make a utilization review determination involving health care services which require pre-authorization and provide notice of a determination to the enrollee by telephone and in writing within three days of receipt of the necessary information.

Section 2-a. Ensures the above changes are retained in law upon the expiration of the existing subdivision 2 on March 31, 2015.

Section 3. Effective date.

Justification

Hospitalized patients must receive pre-authorization from their insurance companies in order to have some health care services covered, including the transfer of a patient from a hospital to a nursing home or rehabilitation center. Currently, the timeframe within which insurance companies must issue this determination is three business days. However, this time frame is too long for many patients, particularly over long holiday weekends, where the patient must wait an additional three to four days in the hospital without beginning to recover.

The current time frame prevents many patients from leaving the hospital as they prepare to be transferred to a rehabilitation facility. These rehabilitation facilities are often prepared to accept the patient, but cannot do so without pre-authorization from the insurance company.

Many of these insurance companies already have customer service representatives available during these days to answer questions from individuals or to sign up individuals for coverage. This bill would shorten the time frame within which approval is required so that hospitalized patients can begin the healing process in a timely manner.

Legislative history

New bill.

Fiscal implications

None.

Effective date

This act shall take effect immediately, provided, however, that sections one-a and two-a of this act shall take effect on the same date and in the same manner as chapter 371 of the laws of 2015, take effect.