NY Pub Health L § 4406-D (2021)
2021 New York Laws PBH - Public Health Article 44 - Health Maintenance Organizations 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.