2023 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.