What's happening
This bill requires the adoption and use of universal forms for health care professional credentialing, re-credentialing, and referrals in New York.
Why it matters
Streamlines provider paperwork. By mandating universal forms for credentialing, re-credentialing, and referrals, the bill aims to reduce the administrative burden on health care professionals and facilities, allowing providers to spend less time on paperwork and more time on patient care.
Promotes faster network participation. The use of standardized forms is likely to speed up the credentialing process, helping newly licensed or relocating health care professionals join insurance networks and start seeing patients more quickly, which could improve access to care.
Reduces inconsistencies and confusion. Universal forms minimize variation between insurance plans and hospitals, making the credentialing and referral processes more predictable and transparent for providers—potentially decreasing errors, delays, and rejections due to form discrepancies.
Aligns with national standards and public programs. The legislation requires the forms be updated to reflect national credentialing standards and include requirements for Medicaid and the Child Health Plus program, ensuring consistency across public and private health plans and potentially facilitating participation in these programs.
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Who cares
Health care professionals
The bill would standardize credentialing applications and referral forms and require an abbreviated form for credentialing renewals.
Managed care plans and insurers
They would have to use the universal credentialing forms and could require only the universal referral form, while retaining the ability to request additional patient information separately.
Hospitals and other health care facilities
They would be required to use the universal forms when credentialing and re-credentialing health care professionals.
Newly licensed health care professionals
The bill would require plans to establish procedures allowing them to provide care and receive payment on a provisional basis while their applications are pending.
Headline styles
Streamline Health Plan Forms
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Committed to rules
- Advanced to third reading
- 2nd report cal.
- 1st report cal.307
- Referred to health
- Committed to rules
- Advanced to third reading
- 2nd report cal.
- 1st report cal.760
- 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.
Standardize Healthcare Forms
Assembly Floor Calendar · Sponsor Richard Gottfried
Full text
5 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
4335
2019-2020 Regular Sessions
IN SENATE
March 7, 2019
Introduced by Sen. SALAZAR -- read twice and ordered printed, and when printed to be committed to the Committee on Health
AN ACT to amend the public health law and the insurance law, in relation to certain application and referral forms for health care plans
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Subdivision 1 of section 4406-d of the public health law, as amended by chapter 425 of the laws of 2016, is amended to read as follows:
1. (a) A health care plan shall, upon request, make available and disclose to health care professionals written application procedures and minimum qualification requirements which a health care professional must meet in order to be considered by the health care plan. The plan shall consult with appropriately qualified health care professionals in developing its qualification requirements. A health care plan shall complete review of the health care professional's universal health care professional application [to participate] for participation in the in-network portion of the health care plan's network and shall, within sixty days of receiving a health care professional's completed universal application to participate in the health care plan's network, notify the health care professional as to: (i) whether he or she is credentialed; or (ii) whether additional time is necessary to make a determination because of a failure of a third party to provide necessary documentation. In such instances where additional time is necessary because of a lack of necessary documentation, a health plan shall make every effort to obtain such information as soon as possible and shall make a final determination within twenty-one days of receiving the necessary documentation.
(b) If the completed application of a newly-licensed health care professional or a health care professional who has recently relocated to this state from another state and has not previously practiced in this state, who joins a group practice of health care professionals each of
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03362-01-9
S. 4335 2
whom participates in the in-network portion of a health care plan's network, is neither approved nor declined within sixty days of submission of a completed application pursuant to paragraph (a) of this subdivision, the health care professional shall be deemed "provisionally credentialed" and may participate in the in-network portion of the health care plan's network; provided, however, that a provisionally credentialed physician may not be designated as an enrollee's primary care physician until such time as the physician has been fully credentialed. The network participation for a provisionally credentialed health care professional shall begin on the day following the sixtieth day of receipt of the completed application and shall last until the final credentialing determination is made by the health care plan. A health care professional shall only be eligible for provisional credentialing if the group practice of health care professionals notifies the health care plan in writing that, should the application ultimately be denied, the health care professional or the group practice: (i) shall refund any payments made by the health care plan for in-network services provided by the provisionally credentialed health care professional that exceed any out-of-network benefits payable under the enrollee's contract with the health care plan; and (ii) shall not pursue reimbursement from the enrollee, except to collect the copayment that otherwise would have been payable had the enrollee received services from a health care professional participating in the in-network portion of a health care plan's network. Interest and penalties pursuant to section three thousand two hundred twenty-four-a of the insurance law shall not be assessed based on the denial of a claim submitted during the period when the health care professional was provisionally credentialed; provided, however, that nothing herein shall prevent a health care plan from paying a claim from a health care professional who is provisionally credentialed upon submission of such claim. A health care plan shall not deny, after appeal, a claim for services provided by a provisionally credentialed health care professional solely on the ground that the claim was not timely filed.
(c) The commissioner, in consultation with the superintendent of financial services, and representatives of health care plans, hospitals and health care professionals shall adopt by regulation such universal health care professional application for participation form, and a form for the renewal of credentialing which shall be an abbreviated version of the universal application form, for use by health care plans which offer managed care products for the purpose of credentialing and re-credentialing health care professionals who seek to participate in a health care plan's provider network, including credentialing and re-credentialing health care professionals who are employed or have staff privileges at hospitals or other health care facilities which seek to participate in a provider network.
(d) The commissioner, in consultation with the superintendent of financial services, and representatives of health care plans, hospitals and health care professionals shall adopt by regulation a universal health care professional referral form for the purpose of simplifying the process of referral of patients to other health care professionals.
(e) The commissioner, in consultation with the superintendent of financial services, and representatives of health care plans, hospitals and health care professionals shall revise the universal application, re-credentialing and universal health care professional referral forms as necessary, to conform with industry-wide, national standards of credentialing, re-credentialing and health care referral.
S. 4335 3
(f) In developing the universal health care professional application re-credentialing forms, the commissioner shall ensure that the credentialing and re-credentialing requirements for participation in the medicaid program and the state child health plus program are adequately reflected on the health care professional application and re-credentialing forms.
(g) All the credentialing and re-credentialing forms required for development under this subdivision shall be the only forms that may be used for credentialing and re-credentialing health care professionals by health care plans, hospitals, and other health care facilities.
(h) The professional referral form required for development under this subdivision shall be the only form that a health care plan may require a health care professional to use for the purposes of making a professional referral; provided, however, that a health care plan may request additional patient information separately from the professional referral form for the purposes of reviewing such professional referral.
§ 2. Subsection (a) of section 4803 of the insurance law, as amended by chapter 425 of the laws of 2016, is amended to read as follows:
(a) (1) An insurer which offers a managed care product shall, upon request, make available and disclose to health care professionals written application procedures and minimum qualification requirements which a health care professional must meet in order to be considered by the insurer for participation in the in-network benefits portion of the insurer's network for the managed care product. The insurer shall consult with appropriately qualified health care professionals in developing its qualification requirements for participation in the in-network benefits portion of the insurer's network for the managed care product. An insurer shall complete review of the health care professional's application to participate in the in-network portion of the insurer's network and, within sixty days of receiving a health care professional's completed application to participate in the insurer's network, will notify the health care professional as to: (A) whether he or she is credentialed; or (B) whether additional time is necessary to make a determination because of a failure of a third party to provide necessary documentation. In such instances where additional time is necessary because of a lack of necessary documentation, an insurer shall make every effort to obtain such information as soon as possible and shall make a final determination within twenty-one days of receiving the necessary documentation. The plans shall also implement procedures to permit newly licensed health care professionals to render care and receive payment for care provided to enrollees on a provisional basis during the pendency of the application process of such newly licensed health care professionals.
(2) If the completed application of a newly-licensed health care professional or a health care professional who has recently relocated to this state from another state and has not previously practiced in this state, who joins a group practice of health care professionals each of whom participates in the in-network portion of an insurer's network, is neither approved nor declined within sixty days of submission of a completed application pursuant to paragraph one of this subsection, such health care professional shall be deemed "provisionally credentialed" and may participate in the in-network portion of an insurer's network; provided, however, that a provisionally credentialed physician may not be designated as an insured's primary care physician until such time as the physician has been fully credentialed. The network participation for a provisionally credentialed health care professional shall begin on the
S. 4335 4
day following the sixtieth day of receipt of the completed application and shall last until the final credentialing determination is made by the insurer. A health care professional shall only be eligible for provisional credentialing if the group practice of health care professionals notifies the insurer in writing that, should the application ultimately be denied, the health care professional or the group practice: (A) shall refund any payments made by the insurer for in-network services provided by the provisionally credentialed health care professional that exceed any out-of-network benefits payable under the insured's contract with the insurer; and (B) shall not pursue reimbursement from the insured, except to collect the copayment or coinsurance that otherwise would have been payable had the insured received services from a health care professional participating in the in-network portion of an insurer's network. Interest and penalties pursuant to section three thousand two hundred twenty-four-a of this chapter shall not be assessed based on the denial of a claim submitted during the period when the health care professional was provisionally credentialed; provided, however, that nothing herein shall prevent an insurer from paying a claim from a health care professional who is provisionally credentialed upon submission of such claim. An insurer shall not deny, after appeal, a claim for services provided by a provisionally credentialed health care professional solely on the ground that the claim was not timely filed.
(3) The superintendent, in consultation with the commissioner of health, and representatives of health care plans, hospitals, and health care professionals shall adopt by regulation a universal health care professional application for participation form, and a form for the renewal of credentialing which shall be an abbreviated version of the universal application form for use by health care plans which offer managed care products for the purpose of credentialing and re-credentialing health care professionals who seek to participate in a health care plan's provider network, including credentialing and re-credentialing health care professionals who are employed or have staff privileges at hospitals or other health care facilities which seek to participate in a provider network.
(4) The superintendent, in consultation with the commissioner of health, and representatives of health care plans, hospitals and health care professionals shall adopt by regulation a universal health care professional referral form for the purpose of simplifying the process of referral of patients to other health care professionals.
(5) The superintendent, in consultation with the commissioner of health, and representatives of health care plans, hospitals and health care professionals shall revise the universal application, re-credentialing and universal health care professional referral forms as necessary, to conform with industry-wide, national standards of credentialing, re-credentialing and health care referral.
(6) In developing the universal health care professional application re-credentialing forms, the superintendent shall ensure that the credentialing and re-credentialing requirements for participation in the medicaid program and the state child health plus program are adequately reflected on the health care professional application and re-credentialing forms.
(7) The credentialing and re-credentialing forms required for development under this subsection shall be the only forms that may be used for credentialing and re-credentialing health care professionals by insurers, hospitals and other health care facilities.
S. 4335 5
(8) The professional referral form required for development under this subsection shall be the only form that an insurer may require a health care professional to use for the purposes of making a professional referral; provided, however, that an insurer may request additional patient information separately from the professional referral form for the purposes of reviewing such professional referral.
§ 3. This act shall take effect on the one hundred eightieth day after it shall have become a law.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the public health law and the insur- ance law, in relation to certain application and referral forms for health care plans
Purpose or general idea of bill
To streamline and simplify the process by which physicians and other health care professionals are credentialed by health care plans and hospitals, as well as to standardize the referral forms that primary care physicians use to facilitate care for a patient by a specialist physician.
Summary of specific provisions
Section 1 of the bill amends section 4406-d, subdivision (1) paragraph(a)of the Public Health Law by adding "universal health care professional" before application, deletes "to participate" and adds "for participation" and creates new paragraphs (c), (d), (e), (f), (g) and (h) to establish a process for creating a standardized credentialing and renewal form for physicians and other health care professionals to use for the purpose of being accepted and retained on the panels of health care plans, as well as for the purpose of obtaining staff privileges at a hospital or other health care facility which seek to participate in a provider network. Such credentialing form would be required to include provisions that would ensure tha t the form would be applicable for physician participation in the networks of government sponsored health plans, including Medicaid a nd Child Health Plus. It would also estab- lish a similar process for creating a uniform referral form that physi- cians and other health care professionals may use in referring patients for specialty care.
Read the full memo (700 words)
Section 2 of the bill amends section 4803 of the Insurance Law requiring plans to implement procedures for new licensed health care professionals to render care and receive payment during the pendency of the applica- tion process and creates new paragraphs (3), (4), (5), (6), (7) and (8) to add identical language as new paragraphs (c), (d), (e), (f), (g) and (h) in Public Health Law described above.
Section 3 of the bill is the effective date.
Justification
Physicians currently need to spend an extensive amount of time complet- ing paperwork in order to be credentialed by health care plans for participation in their networks, and by hospitals to be granted employ- ment of staff privileges. Credentialing is the process by which physi- cians present documentation of their professional privileges, licensure, evidence of malpractice insurance and malpractice history to such health care plan or hospital for their review. While this is an important proc- ess for ensuring that a physician who will provide care for the enrol- lees of a health plan, or of the patients at a hospital, is properly qualified, the process can be unnecessarily cumbersome. Most insurers have different forms that essentially ask for the same information, creating additional unnecessary paperwork for the physician. This legis- lation would simplify this cumbersome process to facilitate the creation of a uniform credentialing and renewal form, and thereby reduce the administrative burden physicians currently have in completing these forms. This legislation calls for the forms to be devised with collab- oration by all parties who regularly complete and review these forms, including health plans, hospitals, physicians and other health care providers.
Moreover, this legislation would also establish a similar process for creating a standard referral form that a primary care physician may use to facilitate making a referral when a patient needs to receive care from a specialist physician. As with credentialing forms, health care plans typically have their own referral authorization forms that are substantially similar, but different such that the physician must use each plan's form. As with the uniform credentialing forms, a universal referral form would alleviate some of the administrative hassles that physicians face in attempting to facilitate necessary care for their patients.
Prior legislative history
2002: A.10483-A - advanced to third reading calendar 2003-04: A.5013 - passed Assembly 2005-06: A.5405 - passed Assembly 2007-08: A.8163 - passed Assembly 2009-10: A.764-A - passed Assembly 2011-2012: A.575 - passed Assembly 2013-2014: A.2673-A - passed Assembly 2015-2016: A.443-A - advanced to third reading calendar 2017-2018: A.2389 - advanced to third reading calendar
Fiscal implications
None
Effective date
This act shall take effect 180 days after it shall have become law.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.