What's happening
This bill amends the definition of clinical peer reviewer in public health and insurance laws, clarifying qualifications and requirements for such reviewers, especially in cases involving substance use disorder treatment.
Why it matters
Narrows and clarifies who can serve as a clinical peer reviewer. by specifying stricter licensing and credentialing requirements, particularly requiring reviewers to have at least five years of specialty experience and, where relevant, board certification or eligibility.
Enhances protections for patients undergoing substance use disorder treatment. by ensuring that peer reviewers in these cases have specialized experience in behavioral health and direct experience with substance use disorder treatment, reducing the likelihood of inappropriate denials by unqualified reviewers.
Standardizes qualifications across medical and non-physician health professionals. (such as psychologists or social workers) participating in utilization review, making sure all have appropriate and current credentials and are in the same or similar specialty as the treating provider.
May improve the quality and fairness of insurance appeals and utilization reviews. , potentially reducing disputes over coverage denials, as decisions must be made by reviewers with direct expertise in the relevant field or condition.
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Who cares
Headline styles
Clarify Peer Reviewer Definition
Plain English, a few words. Used as the page title.
Sponsors
History
- Ordered to third reading cal.202
- Advanced to third reading cal.51
- Reported
- Referred to health
Full text
4 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
2539
2017-2018 Regular Sessions
IN ASSEMBLY
January 20, 2017
Introduced by M. of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, ROSENTHAL, KAVANAGH, COLTON, JAFFEE, ABINANTI, SEPULVEDA -- read once and referred to the Committee on Health
AN ACT to amend the public health law and the insurance law, in relation to the definition of clinical peer reviewer
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Subdivision 2 of section 4900 of the public health law, as amended by chapter 586 of the laws of 1998, item (B) of subparagraph (ii) of paragraph (a) as amended and subparagraph (iii) of paragraph (a) as added by chapter 41 of the laws of 2014, is amended to read as follows:
2. "Clinical peer reviewer" means:
(a) [for purposes of title one of this article:
(i) a physician who possesses a current and valid non-restricted license to practice medicine; or
(ii) a health care professional other than a licensed physician who:
(A) where applicable, possesses a current and valid non-restricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession; and
(B) is in the same profession and same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review; or
(iii) for purposes of a determination involving substance use disorder treatment:
(A) a physician who possesses a current and valid non-restricted license to practice medicine and who specializes in behavioral health and has experience in the delivery of substance use disorder courses of treatment; or
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02208-01-7
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(B) a health care professional other than a licensed physician who specializes in behavioral health and has experience in the delivery of substance use disorder courses of treatment and, where applicable, possesses a current and valid non-restricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession; and
(b) for purposes of title two of this article:
(i)] a physician who:
[(A)] (i) possesses a current and valid non-restricted license to practice medicine under article one hundred thirty-one of the education law;
[(B)] (ii) where applicable, is board certified or board eligible in the same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under appeal;
[(C)] (iii) has been practicing in such area of specialty for a period of at least five years;
(iv) for purposes of a determination involving substance use disorder treatment, possesses a current and valid non-restricted license to practice medicine and specializes in behavioral health and has experience in the delivery of substance use disorder courses of treatment; and
[(D)] (v) is knowledgeable about the health care service or treatment under review or appeal; or
[(ii)] (b) a health care professional other than a licensed physician who possesses a current and valid non-restricted license or certification under title eight of the education law:
[(A)] (i) where applicable, possesses a current and valid non-restricted license, certificate or registration;
[(B)] (ii) where applicable, is credentialed by the national accrediting body appropriate to the profession in the same profession and same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review or appeal;
[(C)] (iii) has been practicing in such area of specialty for a period of at least five years;
[(D)] (iv) is knowledgeable about the health care service or treatment under review or appeal;
(v) for purposes of a determination involving substance use disorder, specializes in behavioral health and has experience in the delivery of substance use disorder courses of treatment and, where applicable, possesses a current and valid non-restricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession; and
[(E)] (vi) where applicable to such health care professional's scope of practice, is clinically supported by a physician who possesses a current and valid non-restricted license to practice medicine.
[(c)] Nothing [herein] in this subdivision shall be construed to change any statutorily-defined scope of practice.
§ 2. Subsection (b) of section 4900 of the insurance law, as amended by chapter 586 of the laws of 1998, item (ii) of subparagraph (B) of paragraph 1 as amended and subparagraph (C) of paragraph 1 as added by chapter 41 of the laws of 2014, is amended to read as follows:
(b) "Clinical peer reviewer" means:
(1) [for purposes of title one of this article:
A. 2539 3
(A) a physician who possesses a current and valid non-restricted license to practice medicine; or
(B) a health care professional other than a licensed physician who:
(i) where applicable, possesses a current and valid non-restricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession; and
(ii) is in the same profession and same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review; or
(C) for purposes of a determination involving substance use disorder treatment:
(i) a physician who possesses a current and valid non-restricted license to practice medicine and who specializes in behavioral health and has experience in the delivery of substance use disorder courses of treatment; or
(ii) a health care professional other than a licensed physician who specializes in behavioral health and has experience in the delivery of substance use disorder courses of treatment and, where applicable, possesses a current and valid non-restricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession; and
(2) for purposes of title two of this article:
(A)] a physician who:
[(i)] (A) possesses a current and valid non-restricted license to practice medicine under article one hundred thirty-one of the education law;
[(ii)] (B) where applicable, is board certified or board eligible in the same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review or appeal;
[(iii)] (C) has been practicing in such area of specialty for a period of at least five years;
(D) for purposes of a determination involving substance use disorder treatment, possesses a current and valid non-restricted license to practice medicine and who specializes in behavioral health and has experience in the delivery of substance use disorder courses of treatment; and
[(iv)] (E) is knowledgeable about the health care service or treatment under review or appeal; or
[(B)] (2) a health care professional other than a licensed physician who possesses a current and valid non-restricted license or certification under title eight of the education law:
[(i)] (A) where applicable, possesses a current and valid non-restricted license, certificate or registration;
[(ii)] (B) where applicable, is credentialed by the national accrediting body appropriate to the profession in the same profession and same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review or appeal;
[(iii)] (C) has been practicing in such area of specialty for a period of at least five years;
[(iv)] (D) for purposes of a determination involving substance use disorder treatment, specializes in behavioral health and has experience in the delivery of substance use disorder courses of treatment and,
A. 2539 4
where applicable, possesses a current and valid non-restricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession;
(E) is knowledgeable about the health care service or treatment under review or appeal; and
[(v)] (F) where applicable to such health care professional's scope of practice, is clinically supported by a physician who possesses a current and valid non-restricted license to practice medicine.
[(3)] Nothing [herein] in this subdivision shall be construed to change any statutorily-defined scope of practice.
§ 3. This act shall take effect on the ninetieth day after it shall have become a law.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
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