2006 New York Code - Health Care Professional Applications And Terminations.

 
    § 4803. Health care professional applications and terminations. (a) 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.
    (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.