NY Ins L § 3224-A (2021)
2021 New York Laws ISC - Insurance Article 32 - Insurance Contracts - Life, Accident and Health, Annuities 3224-A - Standards for Prompt, Fair and Equitable Settlement of Claims for Health Care and Payments for Health Care Services.

§  3224-a.  Standards  for  prompt,  fair  and equitable settlement of claims for health care and payments for health  care  services.  In  the processing  of  all  health  care  claims  submitted  under contracts or agreements issued or entered into pursuant to this article and  articles forty-two,  forty-three  and  forty-seven  of  this  chapter and article forty-four of the public health  law  and  all  bills  for  health  care services rendered by health care providers pursuant to such contracts or agreements,  any  insurer  or  organization  or  corporation licensed or certified pursuant to article forty-three or forty-seven of this chapter or article forty-four of the public  health  law  shall  adhere  to  the following standards:  (a)  Except  in  a  case  where  the  obligation  of  an insurer or an organization or corporation licensed or certified  pursuant  to  article forty-three  or forty-seven of this chapter or article forty-four of the public health law to pay a claim submitted by a policyholder  or  person covered  under  such  policy  ("covered  person") or make a payment to a health care provider is  not  reasonably  clear,  or  when  there  is  a reasonable  basis supported by specific information available for review by the superintendent that such claim or bill for health  care  services rendered  was  submitted  fraudulently,  such insurer or organization or corporation shall pay the claim to a policyholder or covered  person  or make  a  payment to a health care provider within thirty days of receipt of a claim or bill for services rendered that  is  transmitted  via  the internet or electronic mail, or forty-five days of receipt of a claim or bill  for  services  rendered  that is submitted by other means, such as paper or facsimile.  (b) In a case where the obligation of an insurer or an organization or corporation licensed or certified pursuant  to  article  forty-three  or forty-seven  of  this chapter or article forty-four of the public health law to pay a claim or make a payment for health care  services  rendered is  not  reasonably  clear  due  to  a  good faith dispute regarding the eligibility of a person for coverage, the liability of  another  insurer or  corporation or organization for all or part of the claim, the amount of the claim, the benefits covered under a contract or agreement, or the manner in which services  were  accessed  or  provided,  an  insurer  or organization  or  corporation  shall  pay  any undisputed portion of the claim in accordance with this subsection and  notify  the  policyholder, covered  person  or  health  care  provider  in writing, and through the internet or other electronic means for claims submitted in that  manner, within thirty calendar days of the receipt of the claim:  (1)  that  it  is  not  obligated to pay the claim or make the medical payment, stating the specific reasons why it is not liable; or  (2)  to  request  all  additional  information  needed  to   determine liability to pay the claim or make the health care payment; and  (3)  of  the  specific  type  of  plan  or product the policyholder or covered person is enrolled in; provided that  nothing  in  this  section shall authorize discrimination based on the source of payment.   Upon  receipt  of  the  information requested in paragraph two of this subsection or an appeal of a claim or  bill  for  health  care  services denied  pursuant  to  paragraph  one  of  this subsection, an insurer or organization or corporation licensed or certified  pursuant  to  article forty-three  or forty-seven of this chapter or article forty-four of the public health law shall comply with  subsection  (a)  of  this  section; provided, that if the insurer or organization or corporation licensed or certified pursuant to article forty-three or forty-seven of this chapter or  article  forty-four of the public health law determines that payment or additional payment is due on the claim, such payment shall be made to  the policyholder or  covered  person  or  health  care  provider  within fifteen days of the determination.  (c)  (1)  Except as provided in paragraph two of this subsection, each claim or bill for health care services processed in  violation  of  this section  shall  constitute  a  separate  violation.  In  addition to the penalties provided in this  chapter,  any  insurer  or  organization  or corporation  that  fails  to  adhere  to the standards contained in this section shall be obligated to pay to the health care provider or  person submitting the claim, in full settlement of the claim or bill for health care  services,  the  amount  of  the  claim or health care payment plus interest on the amount of such claim  or  health  care  payment  of  the greater  of  the  rate  equal  to  the  rate  set by the commissioner of taxation and finance for corporate taxes pursuant to  paragraph  one  of subsection  (e)  of  section  one  thousand ninety-six of the tax law or twelve percent per annum, to be computed from  the  date  the  claim  or health care payment was required to be made. When the amount of interest due  on  such  a  claim  is  less  then  two  dollars,  and  insurer  or organization or corporation shall not be required  to  pay  interest  on such claim.  (2)   Where   a  violation  of  this  section  is  determined  by  the superintendent as a result of the  superintendent's  own  investigation, examination, audit or inquiry, an insurer or organization or corporation licensed  or certified pursuant to article forty-three or forty-seven of this chapter or article forty-four of the public health law shall not be subject  to  a  civil  penalty  prescribed  in  paragraph  one  of  this subsection,  if  the  superintendent  determines  that  the  insurer  or organization  or  corporation   has   otherwise   processed   at   least ninety-eight  percent  of  the  claims  submitted  in a calendar year in compliance  with  this  section;  provided,  however,  nothing  in  this paragraph  shall limit, preclude or exempt an insurer or organization or corporation from payment of a claim and payment of interest pursuant  to this  section.  This  paragraph  shall  not  apply to violations of this section determined  by  the  superintendent  resulting  from  individual complaints  submitted  to the superintendent by health care providers or policyholders.  (d) For the purposes of this section:  (1) "policyholder" shall mean a person covered under such policy or  a representative designated by such person;  (2)  "health care provider" shall mean an entity licensed or certified pursuant to article twenty-eight, thirty-six  or  forty  of  the  public health  law,  a  facility  licensed  pursuant  to  article  nineteen  or thirty-one of the mental hygiene law, a  fiscal  intermediary  operating under  section  three  hundred  sixty-five of the social services law, a health care professional licensed, registered or certified  pursuant  to title   eight   of  the  education  law,  a  dispenser  or  provider  of pharmaceutical products, services or durable  medical  equipment,  or  a representative designated by such entity or person;  (3) "plan or product" shall mean:  (i)  Medicaid  coverage  provided  pursuant  to  section three hundred sixty-four-j of the social services law;  (ii) a child health  insurance  plan  certified  pursuant  to  section twenty-five hundred eleven of the public health law;  (iii)  basic  health  program  coverage  certified pursuant to section three hundred sixty-nine-gg of the social services  law,  including  the specific rating group the policyholder or covered person is enrolled in;  (iv) coverage purchased on the New York insurance exchange established pursuant  to section two hundred sixty-eight-b of the public health law; and  (v) any other  comprehensive  health  insurance  coverage  subject  to article  thirty-two,  forty-three,  or  forty-seven  of this chapter, or article forty-four of the public health law; and  (4)   "emergency  services"  shall  have  the  meaning  set  forth  in subparagraph (D) of paragraph nine of subsection (i)  of  section  three thousand  two  hundred  sixteen  of  this  article,  subparagraph (D) of paragraph four of subsection (k) of section three thousand  two  hundred twenty-one  of  this  article  and  subparagraph (D) of paragraph two of subsection (a) of section four thousand  three  hundred  three  of  this chapter.  (e)  Nothing  in this section shall in any way be deemed to impair any right available to the state to adjust the timing of  its  payments  for medical  assistance  pursuant  to  title  eleven  of article five of the social services  law,  or  for  child  health  insurance  plan  benefits pursuant  to title one-a of article twenty-five of the public health law or otherwise be deemed to require adjustment of payments  by  the  state for such medical assistance or child health insurance.  (f)  In  any  action  brought  by  the superintendent pursuant to this section or article twenty-four of this chapter relating to this  section regarding  payments  for  medical assistance pursuant to title eleven of article five of the social services law,  child  health  insurance  plan benefits  pursuant  to  title one-a of article twenty-five of the public health law, benefits under the voucher  insurance  program  pursuant  to section  one  thousand  one  hundred  twenty-one  of  this  chapter, and benefits under the  New  York  state  small  business  health  insurance partnership program pursuant to article nine-A of the public health law, it  shall  be  a  mitigating  factor  that  the  insurer, corporation or organization is owed any premium amounts, premium adjustments, stop-loss recoveries or other payments  from  the  state  or  one  of  its  fiscal intermediaries under any such program.  (g)  Time  period  for  submission  of claims. (1) Except as otherwise provided by law, health care  claims  must  be  initially  submitted  by health  care  providers within one hundred twenty days after the date of service to be valid and enforceable against an insurer  or  organization or  corporation licensed or certified pursuant to article forty-three or article forty-seven of this chapter or article forty-four of the  public health  law.  Provided,  however,  that nothing in this subsection shall preclude the parties from agreeing to a time period or other terms which are more favorable to the health care provider. Provided  further  that, in  connection  with  contracts  between  organizations  or corporations licensed or certified pursuant to article forty-three of this chapter or article forty-four of the public health law and  health  care  providers for  the  provision  of  services  pursuant  to  section  three  hundred sixty-four-j or three hundred sixty-nine-ee of the social  services  law or  title  I-A  of article twenty-five of the public health law, nothing herein shall be deemed: (i) to preclude the parties from agreeing  to  a different  time period but in no event less than ninety days; or (ii) to supersede contract provisions in existence at the time  this  subsection takes  effect  except  to  the  extent that such contracts impose a time period of less than ninety days.  (2) This subsection shall not abrogate any right or  reduce  or  limit any  additional  time  period  for  claim  submission provided by law or regulation specifically applicable to coordination of benefits in effect prior to the effective date of this subsection.  (h)  (1)  An  insurer  or  organization  or  corporation  licensed  or certified pursuant to article forty-three or article forty-seven of this chapter  or  article  forty-four of the public health law shall permit a participating health care provider to request reconsideration of a claim  that is denied exclusively because it was untimely submitted pursuant to subsection  (g)  of  this  section.  The  insurer  or  organization   or corporation shall pay such claim pursuant to the provisions of paragraph two  of this subsection if the health care provider can demonstrate both that: (i) the health care provider's non-compliance was a result  of  an unusual  occurrence;  and (ii) the health care provider has a pattern or practice of timely submitting claims in compliance with subdivision  (g) of this section.  (2)  An  insurer  or organization or corporation licensed or certified pursuant to article forty-three or article forty-seven of  this  chapter or   article  forty-four  of  the  public  health  law  may  reduce  the reimbursement due to a health care provider for an untimely  claim  that otherwise  meets the requirements of paragraph one of this subsection by an amount not to exceed twenty-five percent of  the  amount  that  would have  been  paid  had  the  claim  been  submitted  in  a timely manner; provided, however, that nothing in  this  subsection  shall  preclude  a health  care provider and an insurer or organization or corporation from agreeing to a lesser reduction. The provisions of this subsection  shall not apply to any claim submitted three hundred sixty-five days after the date   of  service,  in  which  case  the  insurer  or  organization  or corporation may deny the claim in full.  (i) Except where the parties have developed  a  mutually  agreed  upon process for the reconciliation of coding disputes that includes a review of  submitted  medical  records  to  ascertain  the  correct  coding for payment, a general hospital certified pursuant to  article  twenty-eight of  the  public health law shall, upon receipt of payment of a claim for which payment has been adjusted  based  on  a  particular  coding  to  a patient  including  the  assignment of diagnosis and procedure, have the opportunity to submit the affected claim with medical records supporting the hospital's initial coding of the claim within thirty days of receipt of payment. Upon receipt of such  medical  records,  an  insurer  or  an organization  or  corporation  licensed or certified pursuant to article forty-three or forty-seven of this chapter or article forty-four of  the public health law shall review such information to ascertain the correct coding  for  payment based on national coding guidelines accepted by the centers for Medicare and  Medicaid  services  or  the  American  medical association,  to the extent there are codes for such services, including ICD-10 guidelines to  the  extent  available,  and  process  the  claim, including  the  correct  coding,  in  accordance with the timeframes set forth in subsection (a) of this  section.  In  the  event  the  insurer, organization,  or  corporation  processes  the claim consistent with its initial determination, such decision shall be accompanied by a statement of the insurer, organization or corporation setting forth  the  specific reasons   why  the  initial  adjustment  was  appropriate.  An  insurer, organization, or corporation that increases the  payment  based  on  the information  submitted by the general hospital, shall pay to the general hospital interest on the amount of such increase at the rate set by  the commissioner  of  taxation  and  finance for corporate taxes pursuant to paragraph one of subsection (e) of section one  thousand  ninety-six  of the  tax  law,  to  be  computed from the date thirty days after initial receipt of the claim if transmitted electronically  or  forty-five  days after initial receipt of the claim if transmitted by paper or facsimile. Provided,   however,  a  failure  to  remit  timely  payment  shall  not constitute  a  violation  of  this  section.  Neither  the  initial   or subsequent  processing  of  the  claim  by the insurer, organization, or corporation shall be deemed  an  adverse  determination  as  defined  in section  four thousand nine hundred of this chapter if based solely on a coding determination. Nothing in this subsection shall  apply  to  those  instances  in  which  the  insurer or organization, or corporation has a reasonable suspicion of fraud or abuse or when an insurer, organization, or corporation engages in reasonable fraud, waste  and  abuse  detection efforts;  provided,  however,  to  the  extent  any  subsequent  payment adjustments are made as a result of the fraud, waste and abuse detection processes or efforts, such payment adjustments shall  be  consistent  on the coding guidelines required by this subsection.  (j) An insurer or an organization or corporation licensed or certified pursuant  to  article  forty-three  or  forty-seven  of  this chapter or article forty-four of the public health law or  a  student  health  plan established  or  maintained pursuant to section one thousand one hundred twenty-four  of  this  chapter  shall  accept  claims  submitted  by   a policyholder  or  covered  person,  in  writing,  including  through the internet, by electronic mail or by facsimile.  (k) The  superintendent,  in  conjunction  with  the  commissioner  of health,  shall  convene  a  health  care  administrative  simplification workgroup. The workgroup shall consist of  stakeholders,  including  but not  limited  to, insurers, hospitals, physicians and consumers or their representatives, to study and evaluate mechanisms to reduce health  care administrative   costs   and   complexities   through   standardization, simplification and technology. Areas to be  examined  by  the  workgroup shall   include  claims  submission  and  payment,  claims  attachments, preauthorization   practices,    provider    credentialing,    insurance eligibility  verification, and access to electronic medical records. The workgroup shall report  on  its  findings  and  recommendations  to  the superintendent,  the commissioner of health, the speaker of the assembly and the temporary president of the senate within eighteen months of  the effective date of this subsection.