2012 New York Consolidated Laws
PBH - Public Health
Article 44 - (4400 - 4414) 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
  ninety  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  in
  spite  of the health care plan's best efforts or because of a failure of
  a third party to provide  necessary  documentation,  or  non-routine  or
  unusual  circumstances  require  additional  time  for  review.  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.
    (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 ninety days 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 ninetieth 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.
    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.