Bill Text: NY A06168 | 2015-2016 | General Assembly | Introduced
Bill Title: Relates to the provisional credentialing of physicians.
Spectrum: Slight Partisan Bill (Democrat 3-1)
Status: (Introduced - Dead) 2016-01-06 - referred to insurance [A06168 Detail]
Download: New_York-2015-A06168-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
6168
2015-2016 Regular Sessions
I N A S S E M B L Y
March 16, 2015
___________
Introduced by M. of A. RUSSELL -- read once and referred to the Commit-
tee on Insurance
AN ACT to amend the insurance law and the public health law, in relation
to provider credentialing
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Subsection (a) of section 4803 of the insurance law is
2 amended by adding a new paragraph 3 to read as follows:
3 (3) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
4 TO THIS STATE FROM ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN
5 THIS STATE, OR A PHYSICIAN WHO HAS CHANGED HIS OR HER CORPORATE
6 RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
7 CATION NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO
8 IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO ARTICLE
9 TWENTY-EIGHT OF THE PUBLIC HEALTH LAW, AND WHOSE OTHER EMPLOYED PHYSI-
10 CIANS PARTICIPATE IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK,
11 SHALL BE DEEMED "PROVISIONALLY CREDENTIALED" AND MAY PARTICIPATE IN THE
12 IN-NETWORK PORTION OF AN INSURER'S NETWORK UPON : (I) THE INSURER'S
13 RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTIONS OF THE INSUR-
14 ER'S CREDENTIALING APPLICATION; AND (II) THE INSURER BEING NOTIFIED IN
15 WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN GRANTED HOSPITAL
16 PRIVILEGES PURSUANT TO THEIR REQUIREMENTS OF SECTION TWENTY-EIGHT
17 HUNDRED FIVE-K OF THE PUBLIC HEALTH LAW. HOWEVER, A PROVISIONALLY
18 CREDENTIALED PHYSICIAN SHALL NOT BE DESIGNATED AS AN INSURED'S PRIMARY
19 CARE PHYSICIAN UNTIL SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY CREDEN-
20 TIALED BY THE INSURER. AN INSURER SHALL NOT BE REQUIRED TO MAKE ANY
21 PAYMENTS TO THE LICENSED GENERAL HOSPITAL FOR SERVICES PROVIDED BY A
22 PROVISIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS
23 FULLY CREDENTIALED BY THE INSURER, PROVIDED, HOWEVER, THAT UPON BEING
24 FULLY CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL
25 SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE INSURER'S
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD01972-01-5
A. 6168 2
1 INSUREDS FROM THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE
2 PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI-
3 CATION ULTIMATELY BE DENIED BY THE INSURER, THE INSURER SHALL NOT BE
4 LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPITAL FOR THE SERVICES
5 PROVIDED BY THE PROVISIONALLY CREDENTIALED HEALTH CARE PROFESSIONAL THAT
6 EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER THE INSURED'S CONTRACT
7 WITH THE INSURER; AND THE LICENSED GENERAL HOSPITAL SHALL NOT PURSUE
8 REIMBURSEMENT FORM THE INSURED, EXCEPT TO COLLECT THE COPAYMENT OR COIN-
9 SURANCE THAT OTHERWISE WOULD HAVE BEEN PAYABLE HAD THE INSURED RECEIVED
10 SERVICES FROM A HEALTH CARE PROFESSIONAL PARTICIPATING IN THE IN-NETWORK
11 PORTION OF AN INSURER'S NETWORK.
12 S 2. Subdivision 1 of section 4406-d of the public health law is
13 amended by adding a new paragraph (c) to read as follows:
14 (C) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
15 TO THIS STATE FROM ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN
16 THIS STATE, OR A PHYSICIAN WHO HAS CHANGED HIS OR HER CORPORATE
17 RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
18 CATION NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO
19 IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO ARTICLE
20 TWENTY-EIGHT OF THIS CHAPTER, AND WHOSE OTHER EMPLOYED PHYSICIANS
21 PARTICIPATE IN THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK,
22 SHALL BE DEEMED "PROVISIONALLY CREDENTIALLED" AND MAY PARTICIPATE IN THE
23 IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK UPON: (I) THE PLAN'S
24 RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTION OF THE PLAN'S
25 CREDENTIALING APPLICATION; AND (II) THE HEALTH CARE PLAN BEING NOTIFIED
26 IN WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN GRANTED HOSPITAL
27 PRIVILEGE PURSUANT TO THE REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED
28 FIVE-K OF THIS CHAPTER. HOWEVER, A PROVISIONALLY CREDENTIALED PHYSICIAN
29 SHALL NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL
30 SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY CREDENTIALED BY THE HEALTH
31 CARE PLAN. A HEALTH CARE PLAN SHALL NOT BE REQUIRED TO MAKE ANY PAYMENTS
32 TO THE LICENSED GENERAL HOSPITAL FOR SERVICED PROVIDED BY A PROVI-
33 SIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY
34 CREDENTIALED BY THE HEALTH CARE PLAN, PROVIDED HOWEVER THAT UPON BEING
35 FULLY CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL
36 SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE HEALTH PLAN'S
37 ENROLLEES FROM THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE
38 PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI-
39 CATION ULTIMATELY BE DENIED BY THE HEALTH CARE PLAN, THE HEALTH CARE
40 PLAN SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPI-
41 TAL FOR THE SERVICES PROVIDED BY THE PROVISIONALLY CREDENTIALED HEALTH
42 CARE PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER
43 THE ENROLLEE'S CONTRACT WITH THE HEALTH CARE PLAN AND THE LICENSED
44 GENERAL HOSPITAL SHALL NOT PURSUE REIMBURSEMENT FORM THE ENROLLEE,
45 EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
46 BEEN PAYABLE HAD THE ENROLLEE RECEIVED SERVICES FROM A HEALTH CARE
47 PROFESSIONAL PARTICIPATING IN THE IN-NETWORK PORTION OF AN INSURER'S
48 NETWORK.
49 S 3. This act shall take effect on the ninetieth day after it shall
50 have become a law, and shall apply to applications submitted on or after
51 such date and shall not apply to applications submitted prior to such
52 date if such application is resubmitted in substantially similar form on
53 or after the effective date of this act.
