N.Y. Public Health Law § 4406-d: Health care professional applications and terminations

§ 4406-d. Health care professional applications and terminations. 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 application to participate 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

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

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) 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 health care

plan 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 this

chapter, 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 a health care plan, and whose other

employed physicians participate in the in-network portion of a health

care plan's network, shall be deemed "provisionally credentialed" and

may participate in the in-network portion of a health care plan's

network during this time period upon: (i) the health care plan's receipt

of the hospital and physician's completed sections of the insurer's

credentialing application; and (ii) the health care plan 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 this chapter. However, a provisionally credentialed physician

shall not be designated as an enrollee's primary care physician until

such time as the physician has been fully credentialed by the health

care plan. Notwithstanding any other provision of law, a health care

plan 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 health care plan, 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 health care plan's insureds 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 health care plan, the health care plan 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; 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 a health

care plan's network.

2. (a) A health care plan shall not terminate a contract with a health

care professional unless the health care plan 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.

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

health care plan 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 health care plan;

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

care professional may request a hearing; and

(iv) a time limit for a hearing date which must be held within thirty

days after the date of receipt of a request for a hearing.

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

the health care plan. 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.

(d) 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 health care plan, provisional

reinstatement subject to conditions set forth by the health care plan or

termination of the health care professional. Such decision shall be

provided in writing to the health care professional.

(e) 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 paragraph (e) of subdivision

six of section four thousand four hundred three of this article shall

apply to such termination.

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

from the receipt of the notice of termination.

3. Either party to a contract 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.

4. A health care plan shall develop and implement policies and

procedures to ensure that health care professionals are regularly

informed of information maintained by the health care plan to evaluate

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

care plan shall consult with health care professionals in developing

methodologies to collect and analyze health care professional profiling

data. Health care plans shall provide any such information and profiling

data and analysis to 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 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 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 health care professional's profile and to work cooperatively with

the health care plan to improve performance.

5. No health care plan shall terminate a contract or employment, or

refuse to renew a contract, solely because a health care provider has:

(a) advocated on behalf of an enrollee;

(b) filed a complaint against the health care plan;

(c) appealed a decision of the health care plan;

(d) provided information or filed a report pursuant to section

forty-four hundred six-c of this article; or

(e) requested a hearing or review pursuant to this section.

6. Except as provided herein, no contract or agreement between a

health care plan and a health care professional 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 or review concerning such termination.

7. Any contract provision in violation of this section shall be deemed

to be void and unenforceable.

8. For purposes of this section, "health care plan" shall mean a

health maintenance organization licensed pursuant to article forty-three

of the insurance law or certified pursuant to this article or an

independent practice association certified or recognized pursuant to

this article.

9. 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.