N.Y. Insurance Law § 4803: Health care professional applications and terminations

§ 4803. Health care professional applications and terminations. (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.

(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

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) A newly-licensed physician, a physician who has recently relocated

to this state from another state and has not previously practiced in

this state, or a physician who has changed his or her corporate

relationship such that it results in the issuance of a new tax

identification number under which such physician's services are billed

for and who previously had a participation contract with the insurer

immediately prior to the event that changed his or her corporate

relationship, who becomes employed by a general hospital or diagnostic

and treatment center licensed pursuant to article twenty-eight of the

public health law, or a facility licensed under article sixteen, article

thirty-one or article thirty-two of the mental hygiene law which has a

participating provider contract with an insurer, and whose other

employed physicians participate in the in-network portion of an

insurer's network, shall be deemed "provisionally credentialed" and may

participate in the in-network portion of an insurer's network during

this time period upon: (A) the insurer's receipt of the hospital and

physician's completed sections of the insurer's credentialing

application; and (B) the insurer being notified in writing that the

health care professional has been granted hospital privileges pursuant

to the requirements of section twenty-eight hundred five-k of the public

health law. However, a provisionally credentialed physician shall not be

designated as an insured's primary care physician until such time as the

physician has been fully credentialed by the insurer. Notwithstanding

any other provision of law, an insurer shall not be required to make any

payments to the licensed general hospital, the licensed diagnostic and

treatment center or a facility licensed under article sixteen, article

thirty-one or article thirty-two of the mental hygiene law for the

service provided by a provisionally credentialed physician, until and

unless the physician is fully credentialed by the insurer, provided,

however, that upon being fully credentialed, the licensed general

hospital, the licensed diagnostic and treatment center or a facility

licensed under article sixteen, article thirty-one or article thirty-two

of the mental hygiene law shall be paid for all services provided by the

physician for up to sixty days after submission of the completed

application that the credentialed physician provided to the insurer's

subscribers or members from the date the physician fully met the

requirements to be provisionally credentialed pursuant to this

paragraph. Should the application ultimately be denied by the insurer,

the insurer shall not be liable for any payment to the licensed general

hospital, the licensed diagnostic and treatment center or a facility

licensed under article sixteen, article thirty-one or article thirty-two

of the mental hygiene law for the services provided by the provisionally

credentialed health care professional that exceeds any out-of-network

benefits payable under the insured's contract with the insurer; and the

licensed general hospital, the licensed diagnostic and treatment center

or a facility licensed under article sixteen, article thirty-one or

article thirty-two of the mental hygiene law shall not pursue

reimbursement from the insured, except to collect the copayment or

coinsurance or deductible amount 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.

(b) (1) An insurer shall not terminate a contract with a health care

professional for participation in the in-network benefits portion of the

insurer's network for a managed care product unless the insurer provides

to the health care professional a written explanation of the reasons for

the proposed contract termination and an opportunity for a review or

hearing as hereinafter provided. This section shall not apply in cases

involving imminent harm to patient care, a determination of fraud, or a

final disciplinary action by a state licensing board or other

governmental agency that impairs the health care professional's ability

to practice.

(2) The notice of the proposed contract termination provided by the

insurer to the health care professional shall include:

(i) the reasons for the proposed action;

(ii) notice that the health care professional has the right to request

a hearing or review, at the professional's discretion, before a panel

appointed by the insurer;

(iii) a time limit of not less than thirty days within which a health

care professional may request a hearing or review; and

(iv) a time limit for a hearing date which must be held within not

less than thirty days after the date of receipt of a request for a

hearing.

(3) The hearing panel shall be comprised of three persons appointed by

the insurer. At least one person on such panel shall be a clinical peer

in the same discipline and the same or similar specialty as the health

care professional under review. The hearing panel may consist of more

than three persons, provided however that the number of clinical peers

on such panel shall constitute one-third or more of the total membership

of the panel.

(4) The hearing panel shall render a decision on the proposed action

in a timely manner. Such decision shall include reinstatement of the

health care professional by the insurer, provisional reinstatement

subject to conditions set forth by the insurer or termination of the

health care professional. Such decision shall be provided in writing to

the health care professional.

(5) A decision by the hearing panel to terminate a health care

professional shall be effective not less than thirty days after the

receipt by the health care professional of the hearing panel's decision;

provided, however, that the provisions of subsection (e) of section four

thousand eight hundred four shall apply to such termination.

(6) In no event shall termination be effective earlier than sixty days

from the receipt of the notice of termination.

(c) Either party to a contract for participation in the in-network

benefits portion of an insurer's network for a managed care product may

exercise a right of non-renewal at the expiration of the contract period

set forth therein or, for a contract without a specific expiration date,

on each January first occurring after the contract has been in effect

for at least one year, upon sixty days notice to the other party;

provided, however, that any non-renewal shall not constitute a

termination for purposes of this section.

(d) An insurer shall develop and implement policies and procedures to

ensure that health care providers participating in the the in-network

benefits portion of an insurer's network for a managed care product are

regularly informed of information maintained by the insurer to evaluate

the performance or practice of the health care professional. The insurer

shall consult with health care professionals in developing methodologies

to collect and analyze provider profiling data. Insurers shall provide

any such information and profiling data and analysis to these health

care professionals. Such information, data or analysis shall be provided

on a periodic basis appropriate to the nature and amount of data and the

volume and scope of services provided. Any profiling data used to

evaluate the performance or practice of such a health care professional

shall be measured against stated criteria and an appropriate group of

health care professionals using similar treatment modalities serving a

comparable patient population. Upon presentation of such information or

data, each such health care professional shall be given the opportunity

to discuss the unique nature of the health care professional's patient

population which may have a bearing on the professional's profile and to

work cooperatively with the insurer to improve performance.

(e) No insurer shall terminate or refuse to renew a contract for

participation in the in-network benefits portion of an insurer's network

for a managed care product solely because the health care professional

has (1) advocated on behalf of an insured; (2) has filed a complaint

against the insurer; (3) has appealed a decision of the insurer; (4)

provided information or filed a report pursuant to section forty-four

hundred six-c of the public health law; or (5) requested a hearing or

review pursuant to this section.

(f) Except as provided herein, no contract or agreement between an

insurer and a health care professional for participation in the

in-network benefits portion of an insurer's network for a managed care

product shall contain any provision which shall supersede or impair a

health care professional's right to notice of reasons for termination

and the opportunity for a hearing concerning such termination.

(g) Any contract provision in violation of this section shall be

deemed to be void and unenforceable.

(h) For purposes of this section, "health care professional" shall

mean a health care professional licensed, registered or certified

pursuant to title eight of the education law.