NY Ins L § 3217-B (2021)
2021 New York Laws ISC - Insurance Article 32 - Insurance Contracts - Life, Accident and Health, Annuities 3217-B - Prohibitions.

§  3217-b.  Prohibitions. (a) No insurer subject to this article shall by contract, written policy or written procedure  prohibit  or  restrict any  health  care  provider  from  disclosing to any insured, designated representative or, where appropriate, prospective insured,  (hereinafter collectively  referred to as insured) any information that such provider deems appropriate regarding:  (1) a condition or a course of treatment with an insured including the availability of other therapies, consultations, or tests; or  (2) the provisions, terms, or requirements of the  insurer's  products as they relate to the insured.  (b)  No  insurer  subject  to  this article shall by contract, written policy, written procedure or practice prohibit or  restrict  any  health care  provider from filing a complaint, making a report or commenting to an appropriate governmental body regarding the policies or practices  of such  insurer which the provider believes may negatively impact upon the quality of, or access to, patient care. Nor shall an insurer subject  to this  article  take  any  adverse  action,  including but not limited to refusing to renew or execute a contract or agreement with a health  care provider  as  retaliation  against  a  health care provider for filing a complaint, making a report or commenting to an appropriate  governmental body  regarding  policies or practices of such insurer which may violate this chapter including paragraphs thirty, as added by chapter  forty-one of  the  laws  of  2014,  thirty-one,  thirty-one-a  and  thirty-five of subsection (i) of section  thirty-two  hundred  sixteen  and  paragraphs five,  six,  seven,  seven-a  and  seven-b  of subsection (l) of section thirty-two hundred twenty-one of this article.  (c) No insurer subject to this  article  shall  by  contract,  written policy  or  written  procedure  prohibit  or  restrict  any  health care provider from advocating to the insurer on behalf  of  the  insured  for approval  or  coverage  of  a  particular course of treatment or for the provision of health care services.  (d) No contract or  agreement  between  an  insurer  subject  to  this article  and  a health care provider shall contain any clause purporting to transfer to the health care provider by indemnification or  otherwise any  liability  relating  to  activities,  actions  or  omissions of the insurer as opposed to the health care provider.  (e) Contracts entered into  between  an  insurer  and  a  health  care provider shall include terms which prescribe:  (1)  the  method  by  which  payments  to  a  provider,  including any prospective or retrospective adjustments thereto, shall be calculated;  (2) the time periods within which such calculations will be completed, the dates  upon  which  any  such  payments  and  adjustments  shall  be determined  to  be  due,  and the dates upon which any such payments and adjustments will be made;  (3) a description  of  the  records  or  information  relied  upon  to calculate  any  such  payments and adjustments, and a description of how the provider can access a summary of such calculations and adjustments;  (4) the process to  be  employed  to  resolve  disputed  incorrect  or incomplete  records  or  information and to adjust any such payments and adjustments which have been calculated by relying on any such  incorrect or  incomplete  records  or  information so disputed; provided, however, that nothing  herein  shall  be  deemed  to  authorize  or  require  the disclosure of personally identifiable patient information or information related  to  other  individual  health  care  providers  or  the  plan's proprietary data collection systems, software or  quality  assurance  or utilization review methodologies; and  (5)  the right of either party to the contract to seek resolution of a dispute arising pursuant to the payment terms of such contracts  through  a  proceeding  under  article seventy-five of the civil practice law and rules.  (f)  No  contract  entered  into  between an insurer and a health care provider shall be  enforceable  if  it  includes  terms  which  transfer financial   risk  to  providers,  in  a  manner  inconsistent  with  the provisions of paragraph (c) of subdivision  one  of  section  forty-four hundred  three  of  the  public  health  law,  or penalize providers for unfavorable case mix so as to jeopardize the  quality  of  or  insureds' appropriate  access  to medically necessary services; provided, however, that payment at less than prevailing fee for service rates or capitation shall not be deemed or presumed prima facie  to  jeopardize  quality  or access.  (g)(1) No insurer shall implement an adverse reimbursement change to a contract  with a health care professional that is otherwise permitted by the contract, unless, prior to the effective date  of  the  change,  the insurer  gives  the  health  care professional with whom the insurer has directly contracted and who is impacted  by  the  adverse  reimbursement change,  at  least  ninety  days  written  notice  of the change. If the contracting health care professional objects to the change that  is  the subject  of the notice by the insurer, the health care professional may, within thirty days of the date of the notice, give written notice to the insurer to terminate his or her contract with the insurer effective upon the implementation date of the adverse  reimbursement  change.  For  the purposes  of  this  subsection,  the term "adverse reimbursement change" shall mean a proposed change that could reasonably be expected to have a material adverse impact on the aggregate level of payment  to  a  health care  professional, and the term "health care professional" shall mean a health care professional licensed, registered or certified  pursuant  to title eight of the education law. The notice provisions required by this subsection  shall not apply where: (A) such change is otherwise required by law, regulation or applicable regulatory authority, or is required as a result of changes  in  fee  schedules,  reimbursement  methodology  or payment  policies  established by a government agency or by the American Medical  Association's  current  procedural  terminology  (CPT)   codes, reporting  guidelines  and  conventions; or (B) such change is expressly provided for under the terms of the contract  by  the  inclusion  of  or reference  to  a specific fee or fee schedule, reimbursement methodology or payment policy indexing mechanism.  (2) Nothing in this subsection shall create a private right of  action on  behalf  of  a  health  care  professional  against  an  insurer  for violations of this subsection.  (h) Any contract provision, written policy  or  written  procedure  in violation of this section shall be deemed to be void and unenforceable.   * (i)  If  a contract between an insurer and a hospital is not renewed or is terminated by either party, the parties shall continue to abide by the terms of such contract, including reimbursement terms, for a  period of  two months from the effective date of termination or, in the case of a non-renewal, from the end of the  contract  period.  Notice  shall  be provided  to  all  insureds  potentially affected by such termination or non-renewal within fifteen days  after  commencement  of  the  two-month period. The commissioner of health shall have the authority to waive the two-month  period upon the request of either party to a contract that is being terminated for cause. This subsection shall not apply  where  both parties  mutually agree in writing to the termination or non-renewal and the insurer provides notice to the  insured  at  least  thirty  days  in advance of the date of contract termination.   * NB Repealed June 30, 2023  (j)  (1) No insurer shall by contract, written policy or procedure, or by any other  means,  deny  payment  to  a  general  hospital  certified pursuant  to  article  twenty-eight of the public health law for a claim for medically necessary inpatient  services,  observation  services,  or emergency  department  services provided by a general hospital solely on the basis  that  the  general  hospital  did  not  comply  with  certain administrative  requirements  of  such  insurer  with  respect  to those services.  (2) Nothing in this subsection shall preclude a general  hospital  and an insurer from agreeing to certain administrative requirements relating to  payment  for  inpatient services, observation services, or emergency department services, including but not limited  to  timely  notification that  medically  necessary  inpatient services have been provided and to reductions in payment for failure to comply with certain  administrative requirements  including timely notification; provided, however that: (A) any requirement for timely notification must provide  for  a  reasonable extension  of  timeframes  for  notification  for  services  provided on weekends or federal holidays, (B) any agreed to reduction in payment for failure  to   meet   administrative   requirements,   including   timely notification  shall not exceed seven and one-half percent of the payment amount otherwise due for the services provided, and (C)  any  agreed  to reduction  in  payment  for  failure to meet administrative requirements including timely notification shall not  be  imposed  if  the  patient's insurance  coverage  could  not  be  determined  by  the  hospital after reasonable efforts at the time the services were provided.  (3) The provisions of this subsection shall not apply to the denial of a claim: (A) based on a reasonable belief by  an  insurer  of  fraud  or intentional   misconduct   resulting  in  misrepresentation  of  patient diagnosis or  the  services  provided,  or  abusive  billing;  (B)  when required  by  a  state or federal government program or coverage that is provided by this state or  a  municipality  thereof  to  its  respective employees, retirees or members; (C) that is a duplicate claim, that is a claim  submitted  late  pursuant to subsection (g) of section thirty-two hundred twenty-four-a of this article, or is for services for a  benefit that  is  not  covered  under  the  insured's  policy  or  for a patient determined to be ineligible for coverage; (D)  except  in  the  case  of medically  necessary  inpatient  services  resulting  from  an emergency admission,  where  there  is  not  an  existing  participating  provider agreement  between  an  insurer and a general hospital; or (E) where the hospital has repeatedly and systematically,  over  the  previous  twelve month  period, failed to seek prior authorization for services for which prior authorization was required.  (4) For purposes of this subsection, an  "administrative  requirement" shall  not  include  requirements: (A) imposed on an insurer or provider pursuant to federal or state  laws,  regulations  or  guidance;  or  (B) established  by  the  state or federal government applicable to insurers offering benefits under a state or federal government program.  (5) The prohibition on denials set forth in this subsection shall  not apply  to  claims  for services for which a request for preauthorization was denied by the insurer prior to delivery of the service.  (k) An insurer shall not require a prior  authorization  determination for  services  provided  in  a neonatal intensive care unit of a general hospital certified pursuant to article twenty-eight of the public health law. Nothing in this subsection shall prohibit an insurer from denying a claim for such services if the services are subsequently determined  not medically necessary.  (l) At least sixty days prior to the termination of a contract between a  hospital  and an insurer, the parties shall utilize a mutually agreed  upon mediator to assist in resolving any outstanding contractual issues. The results of the mediation shall not be binding on the parties.