Speed Up Nursing Home Reviews

Section 1. Paragraphs (a) and (c) of subdivision 3 of section 4903 of the public health law, paragraph (a) as amended and paragraph (c) as added by chapter 41 of the laws of 2014, are amended to read as follows:

(a) A utilization review agent shall make a determination involving continued or extended health care services, additional services for an enrollee undergoing a course of continued treatment prescribed by a health care provider, or requests for inpatient substance use disorder treatment, or nursing home care or home health care services following an inpatient hospital admission, and shall provide notice of such determination to the enrollee or the enrollee's designee, which may be satisfied by notice to the enrollee's health care provider, by telephone and in writing within one business day of receipt of the necessary information except, with respect to home health care services following an inpatient hospital admission, within seventy-two hours of receipt of the necessary information when the day subsequent to the request falls on a weekend or holiday and except, with respect to inpatient substance use disorder treatment or nursing home care, within twenty-four hours of receipt of the request for services when the request is submitted at least twenty-four hours prior to discharge from an inpatient admission. Notification of continued or extended services shall include the number of extended services approved, the new total of approved services, the date of onset of services and the next review date.

(c) Provided that a request for inpatient treatment for substance use disorder or nursing home care is submitted to the utilization review

EXPLANATION--Matter in italics (underscored) is new; matter in brackets

[ ] is old law to be omitted.

LBD03578-01-9

A. 3059 2

agent at least twenty-four hours prior to discharge from an inpatient admission pursuant to this subdivision, a utilization review agent shall not deny, on the basis of medical necessity or lack of prior authorization, coverage for the inpatient substance use disorder treatment or nursing home care while a determination by the utilization review agent is pending.

§ 2. Paragraphs 1 and 3 of subsection (c) of section 4903 of the insurance law, paragraph 1 as amended and paragraph 3 as added by chapter 41 of the laws of 2014, are amended to read as follows:

(1) A utilization review agent shall make a determination involving continued or extended health care services, additional services for an insured undergoing a course of continued treatment prescribed by a health care provider, or requests for inpatient substance use disorder treatment, or nursing home care or home health care services following an inpatient hospital admission, and shall provide notice of such determination to the insured or the insured's designee, which may be satisfied by notice to the insured's health care provider, by telephone and in writing within one business day of receipt of the necessary information except, with respect to home health care services following an inpatient hospital admission, within seventy-two hours of receipt of the necessary information when the day subsequent to the request falls on a weekend or holiday and except, with respect to inpatient substance use disorder treatment or nursing home care, within twenty-four hours of receipt of the request for services when the request is submitted at least twenty-four hours prior to discharge from an inpatient admission. Notification of continued or extended services shall include the number of extended services approved, the new total of approved services, the date of onset of services and the next review date.

(3) Provided that a request for inpatient treatment for substance use disorder or nursing home care is submitted to the utilization review agent at least twenty-four hours prior to discharge from an inpatient admission pursuant to this subsection, a utilization review agent shall not deny, on the basis of medical necessity or lack of prior authorization, coverage for the inpatient substance use disorder treatment or nursing home care while a determination by the utilization review agent is pending.

§ 3. This act shall take effect on the ninetieth day after it shall have become a law.