2023 New York Laws › ISC - Insurance › Article 48 - Managed Care Health Insurance Contracts › 4803 - Health Care Professional Applications and Terminations.

§  4803.  Health care professional applications and terminations.  (a)
(1) An insurer which offers a managed care product 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
insurer for participation in the  in-network  benefits  portion  of  the
insurer's  network  for  the  managed  care  product.  The insurer shall
consult  with  appropriately  qualified  health  care  professionals  in
developing  its  qualification  requirements  for  participation  in the
in-network benefits portion of the insurer's  network  for  the  managed
care  product.  An  insurer  shall  complete  review  of the health care
professional's application to participate in the in-network  portion  of
the  insurer's network and, within sixty days of receiving a health care
professional's completed application to  participate  in  the  insurer's
network,  will notify the health care professional as to: (A) whether he
or she is credentialed; or (B) 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, an insurer 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.
(2) 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 an insurer's network, is
neither approved nor declined within  sixty  days  of  submission  of  a
completed application pursuant to paragraph one of this subsection, such
health  care  professional  shall be deemed "provisionally credentialed"
and may participate in the in-network portion of an  insurer's  network;
provided,  however,  that a provisionally credentialed physician may not
be designated as an insured'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  insurer.  A  health  care  professional  shall only be eligible for
provisional  credentialing  if  the  group  practice  of   health   care
professionals   notifies   the  insurer  in  writing  that,  should  the
application ultimately be denied, the health care  professional  or  the
group  practice:  (A)  shall refund any payments made by the insurer for
in-network services provided by the  provisionally  credentialed  health
care  professional that exceed any out-of-network benefits payable under
the insured's contract with  the  insurer;  and  (B)  shall  not  pursue
reimbursement  from  the  insured,  except  to  collect the copayment or
coinsurance that otherwise would  have  been  payable  had  the  insured
received  services  from a health care professional participating in the
in-network portion of  an  insurer's  network.  Interest  and  penalties
pursuant  to  section  three  thousand two hundred twenty-four-a of this
chapter 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  an
insurer  from  paying  a  claim  from  a health care professional who is
provisionally credentialed upon submission of  such  claim.  An  insurer
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.
(3) 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  insurer
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 the
public health law, 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  an  insurer,  and  whose  other
employed  physicians  participate  in  the  in-network  portion  of   an
insurer's  network, shall be deemed "provisionally credentialed" and may
participate in the in-network portion of  an  insurer's  network  during
this  time  period  upon:  (A) the insurer's receipt of the hospital and
physician's  completed   sections   of   the   insurer's   credentialing
application;  and  (B)  the  insurer  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 the public
health law. However, a provisionally credentialed physician shall not be
designated as an insured's primary care physician until such time as the
physician  has  been  fully credentialed by the insurer. Notwithstanding
any other provision of law, an insurer 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  insurer,  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  insurer's
subscribers  or  members  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 insurer,
the insurer 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 that  exceeds  any  out-of-network
benefits  payable under the insured's contract with the insurer; 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 an insurer's network.
(b) (1) An insurer shall not terminate a contract with a  health  care
professional for participation in the in-network benefits portion of the
insurer's network for a managed care product unless the insurer 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.
(2)  The  notice  of the proposed contract termination provided by the
insurer 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 insurer;
(iii)  a time limit of not less than thirty days within which a health
care professional may request a hearing or review; and
(iv) a time limit for a hearing date which must  be  held  within  not
less  than  thirty  days  after  the  date of receipt of a request for a
hearing.
(3) The hearing panel shall be comprised of three persons appointed by
the insurer. 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.
(4) 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  insurer,  provisional  reinstatement
subject  to  conditions  set  forth by the insurer or termination of the
health care professional. Such decision shall be provided in writing  to
the health care professional.
(5)  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 subsection (e) of section four
thousand eight hundred four shall apply to such termination.
(6) In no event shall termination be effective earlier than sixty days
from the receipt of the notice of termination.
(c)  Either  party  to  a contract for participation in the in-network
benefits portion of an insurer's network for a managed care product  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.
(d) An insurer shall develop and implement policies and procedures  to
ensure  that  health  care providers participating in the the in-network
benefits portion of an insurer's network for a managed care product  are
regularly  informed of information maintained by the insurer to evaluate
the performance or practice of the health care professional. The insurer
shall consult with health care professionals in developing methodologies
to collect and analyze provider profiling data. Insurers  shall  provide
any  such  information  and  profiling data and analysis to these 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 such 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 such 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 professional's profile and to
work cooperatively with the insurer to improve performance.
(e)  No  insurer  shall  terminate  or  refuse to renew a contract for
participation in the in-network benefits portion of an insurer's network
for a managed care product solely because the health  care  professional
has  (1)  advocated  on  behalf of an insured; (2) has filed a complaint
against the insurer; (3) has appealed a decision  of  the  insurer;  (4)
provided  information  or  filed a report pursuant to section forty-four
hundred six-c of the public health law; or (5) requested  a  hearing  or
review pursuant to this section.
(f)  Except  as  provided  herein, no contract or agreement between an
insurer  and  a  health  care  professional  for  participation  in  the
in-network  benefits  portion of an insurer's network for a managed care
product 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 concerning such termination.
(g) Any contract provision in  violation  of  this  section  shall  be
deemed to be void and unenforceable.
(h)  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.