What's happening
This bill amends the definition of "clinical peer reviewer" in public health and insurance law, specifying qualifications for medical and behavioral health review determinations.
Why it matters
Tightens qualifications for clinical peer reviewers. The bill introduces more specific requirements for peer reviewers, such as mandating board certification (or eligibility), a minimum of five years’ experience in the specialty, and relevant expertise for behavioral health and substance use disorder cases. This could mean more knowledgeable reviewers, potentially resulting in fairer and more clinically appropriate utilization review decisions.
Distinguishes requirements for medical and behavioral health reviews. The amendments make explicit that, for reviews involving mental health or substance use disorders, reviewers must not only be licensed and experienced in behavioral health, but also have direct experience delivering the relevant types of treatment. This is intended to ensure that complex behavioral health decisions are reviewed by true subject-matter experts.
May impact insurance approval and appeals processes. By specifying that reviewers must be specialists in the area under review (including for appeals), the bill could reduce denials based on non-expert judgments, potentially leading to more approvals for medically necessary treatments, especially in behavioral health and substance use cases.
Seeks to prevent scope-of-practice overreach. The bill clarifies that nothing in the new language changes existing professional practice boundaries, aiming to ensure peer review remains within legal and professional limits, which may protect patients and providers from inappropriate determinations.
Albany, before your first meeting.
Every bill that moved yesterday, summarized in a sentence and ranked by impact. The Albany Scorecard follows on Sundays.
Free. Unsubscribe in one click. Want alerts on specific bills? Create an account.
Who cares
Headline styles
Clarify Peer Reviewer Rules
Plain English, a few words. Used as the page title.
Sponsors
History
- Referred to rules
- Delivered to senate
- Passed assembly
- Ordered to third reading cal.128
- Amended on third reading 3076a
- Vote reconsidered - restored to third reading
- Returned to assembly
- Recalled from senate
- Referred to health
- Delivered to senate
- Passed assembly
- Advanced to third reading cal.338
Show 2 earlier actions
- Reported
- Referred to health
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Clarify Clinical Reviewer Rules
In Senate Committee · Rules · Sponsor Brian Benjamin
Full text
5 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
3076--A Cal. No. 338
2019-2020 Regular Sessions
IN ASSEMBLY
January 28, 2019
Introduced by M. of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, L. ROSENTHAL, COLTON, JAFFEE, ABINANTI, D'URSO, LIFTON -- read once and referred to the Committee on Health -- advanced to a third reading, passed by Assembly and delivered to the Senate, recalled from the Senate, vote reconsidered, bill amended, ordered reprinted, retaining its place on the order of third reading
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 by chapter 41 of the laws of 2014 and subparagraph (iii) as amended and subparagraph (iv) of paragraph (a) as added by section 42 of subpart A of part BB of chapter 57 of the laws of 2019, 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:
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03373-03-9
A. 3076--A 2
(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
(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; or
(iv) for purposes of a determination involving treatment for a mental health condition:
(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 mental health courses of treatment; or
(B) a health care professional other than a licensed physician who specializes in behavioral health and has experience in the delivery of a mental health 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 review or appeal;
[(C)] (iii) has been practicing in such area of specialty for a period of at least five years; [and]
(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;
(v) for purposes of a determination involving treatment for a mental health condition, possesses a current and valid non-restricted license to practice medicine and who specializes in behavioral health and has experience in the delivery of mental health courses of treatment; and
[(D)] (vi) 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;
A. 3076--A 3
[(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; [and]
(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;
(vi) for purposes of a determination involving treatment for a mental health condition, specializes in behavioral health and has experience in the delivery of mental health 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)] (vii) 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 by chapter 41 of the laws of 2014, subparagraph (C) as amended and subparagraph (D) of paragraph 1 as added by section 36 of subpart A of part BB of chapter 57 of the laws of 2019, is amended to read as follows:
(b) "Clinical peer reviewer" means:
(1) [for purposes of title one of this article:
(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; or
A. 3076--A 4
(D) for purposes of a determination involving treatment for a mental health condition:
(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 mental health 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 mental health 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; [and]
(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;
(E) for purposes of a determination involving treatment for a mental health condition, possesses a current and valid non-restricted license to practice medicine and who specializes in behavioral health and has experience in the delivery of mental health courses of treatment; and
[(iv)] (F) 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, 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) for purposes of a determination involving treatment for a mental health condition, specializes in behavioral health and has experience in the delivery of mental health courses of treatment and, where applica-
A. 3076--A 5
ble, 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;
(F) is knowledgeable about the health care service or treatment under review or appeal; and
[(v)] (G) 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 same date and in the same manner as subpart A of part BB of chapter 57 of the laws of 2019, or on the ninetieth day after it shall have become a law, whichever is later.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.