2006 New York Code - Standards For Prompt, Fair And Equitable Settlement Of Claims For Health Care And Payments For Health Care Services.

 
    §  3224-a.  Standards  for  prompt,  fair  and equitable settlement of
  claims for health care and payments for health  care  services.  In  the
  processing  of  all  health  care  claims  submitted  under contracts or
  agreements issued or  entered  into  pursuant  to  articles  thirty-two,
  forty-two  and forty-three of this chapter and article forty-four of the
  public health law and all bills for health  care  services  rendered  by
  health  care  providers  pursuant  to  such contracts or agreements, any
  insurer or organization or corporation licensed or certified pursuant to
  article forty-three of this chapter or article forty-four of the  public
  health law shall adhere to the following standards:
    (a)  Except  in  a  case  where  the  obligation  of  an insurer or an
  organization or corporation licensed or certified  pursuant  to  article
  forty-three  of  this chapter or article forty-four of the public health
  law to pay a claim submitted by a policyholder or person  covered  under
  such  policy  or  make  a  payment  to  a  health  care  provider is not
  reasonably clear, or when there  is  a  reasonable  basis  supported  by
  specific  information  available  for  review by the superintendent that
  such claim or bill for  health  care  services  rendered  was  submitted
  fraudulently,  such insurer or organization or corporation shall pay the
  claim to a policyholder or covered person or make a payment to a  health
  care  provider  within forty-five days of receipt of a claim or bill for
  services rendered.
    (b) In a case where the obligation of an insurer or an organization or
  corporation licensed or certified pursuant  to  article  forty-three  of
  this  chapter  or  article  forty-four of the public health law to pay a
  claim or make a  payment  for  health  care  services  rendered  is  not
  reasonably  clear  due to a good faith dispute regarding the eligibility
  of  a  person  for  coverage,  the  liability  of  another  insurer   or
  corporation  or organization for all or part of the claim, the amount of
  the claim, the benefits covered under a contract or  agreement,  or  the
  manner  in  which  services  were  accessed  or  provided, an insurer or
  organization or corporation shall pay  any  undisputed  portion  of  the
  claim  in  accordance  with this subsection and notify the policyholder,
  covered person or health care provider in writing within thirty calendar
  days of the receipt of the claim:
    (1) that it is not obligated to pay the  claim  or  make  the  medical
  payment, stating the specific reasons why it is not liable; or
    (2)   to  request  all  additional  information  needed  to  determine
  liability to pay the claim or make the health care payment.
    Upon receipt of the information requested in  paragraph  two  of  this
  subsection  or  an  appeal  of  a claim or bill for health care services
  denied pursuant to paragraph one  of  this  subsection,  an  insurer  or
  organization  or corporation licensed pursuant to article forty-three of
  this chapter or article forty-four of the public health law shall comply
  with subsection (a) of this section.
    (c) Each claim or bill for health care services processed in violation
  of this section shall constitute a separate violation.  In  addition  to
  the  penalties  provided in this chapter, any insurer or organization or
  corporation that fails to adhere to  the  standards  contained  in  this
  section  shall be obligated to pay to the health care provider or person
  submitting the claim, in full settlement of the claim or bill for health
  care services, the amount of the  claim  or  health  care  payment  plus
  interest  on  the  amount  of  such  claim or health care payment of the
  greater of the rate equal  to  the  rate  set  by  the  commissioner  of
  taxation  and  finance  for corporate taxes pursuant to paragraph one of
  subsection (e) of section one thousand ninety-six  of  the  tax  law  or
  twelve  percent  per  annum,  to  be computed from the date the claim or
  health care payment was required to be made. When the amount of interest
  due on such a claim is less then two dollars, an insurer or organization
  or corporation shall not be required to pay interest on such claim.
    (d) For the purposes of this section:
    (1)  "policyholder" shall mean a person covered under such policy or a
  representative designated by such person; and
    (2) "health care provider" shall mean an entity licensed or  certified
  pursuant  to  article  twenty-eight,  thirty-six  or forty of the public
  health  law,  a  facility  licensed  pursuant   to   article   nineteen,
  twenty-three  or  thirty-one  of  the  mental hygiene law, a health care
  professional licensed, registered or certified pursuant to  title  eight
  of  the  education  law,  a  dispenser  or  provider  of  pharmaceutical
  products, services or durable medical  equipment,  or  a  representative
  designated by such entity or person.
    (e)  Nothing  in this section shall in any way be deemed to impair any
  right available to the state to adjust the timing of  its  payments  for
  medical  assistance  pursuant  to  title  eleven  of article five of the
  social services  law,  or  for  child  health  insurance  plan  benefits
  pursuant  to title one-a of article twenty-five of the public health law
  or otherwise be deemed to require adjustment of payments  by  the  state
  for such medical assistance or child health insurance.
    (f)  In  any  action  brought  by  the superintendent pursuant to this
  section or article twenty-four of this chapter relating to this  section
  regarding  payments  for  medical assistance pursuant to title eleven of
  article five of the social services law,  child  health  insurance  plan
  benefits  pursuant  to  title one-a of article twenty-five of the public
  health law, benefits under the voucher  insurance  program  pursuant  to
  section  one  thousand  one  hundred  twenty-one  of  this  chapter, and
  benefits under the  New  York  state  small  business  health  insurance
  partnership program pursuant to article nine-A of the public health law,
  it  shall  be  a  mitigating  factor  that  the  insurer, corporation or
  organization is owed any premium amounts, premium adjustments, stop-loss
  recoveries or other payments  from  the  state  or  one  of  its  fiscal
  intermediaries under any such program.