New York Laws
Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations
4325 - Prohibitions.

(1) a condition or a course of treatment with a subscriber including
the availability of other therapies, consultations, or tests; or
(2) the provisions, terms, or requirements of the corporation's
products as they relate to the subscriber.
(b) No corporation organized under this article shall by contract,
written policy, written procedure or practice prohibit or restrict any
health care provider from filing a complaint, making a report or
commenting to an appropriate governmental body regarding the policies or
practices of such corporation which the provider believes may negatively
impact upon the quality of or access to patient care. Nor shall a
corporation organized under this article take any adverse action,
including but not limited to refusing to renew or execute a contract or
agreement with a health care provider as retaliation against a health
care provider for filing a complaint, making a report or commenting to
an appropriate governmental body regarding policies or practices of such
corporation which may violate this chapter including subsection (g),
(k), (1), (1-1) or (1-2) of section forty-three hundred three of this
article.
(c) No corporation organized under this article shall by contract,
written policy or written procedure prohibit or restrict any health care
provider from advocating to the corporation on behalf of the subscriber
for approval or coverage of a particular course of treatment.
(d) No contract or agreement between a corporation organized under
this article and a health care provider shall contain any clause
purporting to transfer to the health care provider by indemnification or
otherwise any liability relating to activities, actions or omissions of
the corporation as opposed to the health care provider.
(e) Contracts entered into between an insurer and a health care
provider shall include terms which prescribe:
(1) the method by which payments to a provider, including any
prospective or retrospective adjustments thereto, shall be calculated;
(2) the time periods within which such calculations will be completed,
the dates upon which any such payments and adjustments shall be
determined to be due, and the rates upon which any such payments and
adjustments will be made;
(3) a description of the records or information relied upon to
calculate any such payments and adjustments, and a description of how
the provider can access a summary of such calculations and adjustments;
(4) the process to be employed to resolve disputed incorrect or
incomplete records or information and to adjust any such payments and
adjustments which have been calculated by relying on any such incorrect
or incomplete records or information so disputed; provided, however,
that nothing herein shall be deemed to authorize or require the
disclosure of personally identifiable patient information or information
related to other individual health care providers or the plan's
proprietary data collection systems, software or quality assurance or
utilization review methodologies; and
(5) the right of either party to the contract to seek resolution of a
dispute arising pursuant to the payment terms of such contract through a
proceeding under article seventy-five of the civil practice law and
rules.
(f) No contract entered into between an insurer and a health care
provider shall be enforceable if it includes terms which transfer
financial risk to providers, in a manner inconsistent with the
provisions of paragraph (c) of subdivision one of section forty-four
hundred three of the public health law, or penalize providers for
unfavorable case mix so as to jeopardize the quality of or insureds'
appropriate access to medically necessary services; provided, however,
that payment at less than prevailing fee for service rates or capitation
shall not be deemed or presumed prima facie to jeopardize quality or
access.
(g)(1) No insurer shall implement an adverse reimbursement change to a
contract with a health care professional that is otherwise permitted by
the contract, unless, prior to the effective date of the change, the
insurer gives the health care professional with whom the insurer has
directly contracted and who is impacted by the adverse reimbursement
change, at least ninety days written notice of the change. If the
contracting health care professional objects to the change that is the
subject of the notice by the insurer, the health care professional may,
within thirty days of the date of the notice, give written notice to the
insurer to terminate his or her contract with the insurer effective upon
the implementation date of the adverse reimbursement change. For the
purposes of this subsection, the term "adverse reimbursement change"
shall mean a proposed change that could reasonably be expected to have a
material adverse impact on the aggregate level of payment to a health
care professional, and the term "health care professional" shall mean a
health care professional licensed, registered or certified pursuant to
title eight of the education law. The notice provisions required by this
subsection shall not apply where: (A) such change is otherwise required
by law, regulation or applicable regulatory authority, or is required as
a result of changes in fee schedules, reimbursement methodology or
payment policies established by a government agency or by the American
Medical Association's current procedural terminology (CPT) codes,
reporting guidelines and conventions; or (B) such change is expressly
provided for under the terms of the contract by the inclusion of or
reference to a specific fee or fee schedule, reimbursement methodology
or payment policy indexing mechanism.
(2) Nothing in this subsection shall create a private right of action
on behalf of a health care professional against an insurer for
violations of this subsection.
(h) No corporation or insurer organized or licensed under this chapter
which provides coverage for prescription drugs shall require, or enter
into a contract which permits, a copayment which exceeds the usual and
customary cost of such prescribed drug.
(i) Any contract provision, written policy or written procedure in
violation of this section shall be deemed to be void and unenforceable.
* (j) If a contract between a corporation and a hospital is not
renewed or is terminated by either party, the parties shall continue to
abide by the terms of such contract, including reimbursement terms, for
a period of two months from the effective date of termination or, in the
case of a non-renewal, from the end of the contract period. Notice shall
be provided to all subscribers potentially affected by such termination
or non-renewal within fifteen days after commencement of the two-month
period. The commissioner of health shall have the authority to waive the
two-month period upon the request of either party to a contract that is
being terminated for cause. This subsection shall not apply where both
parties mutually agree in writing to the termination or non-renewal and
the corporation provides notice to the subscriber at least thirty days
in advance of the date of contract termination.

* NB Repealed June 30, 2025
(k) (1) No corporation organized under this article shall by written
contract, written policy or procedure, or by any other means, deny
payment to a general hospital certified pursuant to article twenty-eight
of the public health law for a claim for medically necessary inpatient
services, observation services, or emergency department services
provided by a general hospital solely on the basis that the general
hospital did not comply with certain administrative requirements of such
corporation with respect to those services.
(2) Nothing in this subsection shall preclude a general hospital and a
corporation from agreeing to certain administrative requirements
relating to payment for inpatient services, observation services, or
emergency department services, including, but not limited to timely
notification that medically necessary inpatient services have been
provided and to reductions in payment for failure to comply with certain
administrative requirements including timely notification; provided,
however that: (A) any requirement for timely notification must provide
for a reasonable extension of timeframes for notification for services
provided on weekends or federal holidays, (B) any agreed to reduction in
payment for failure to meet administrative requirements including timely
notification shall not exceed seven and one-half percent of the payment
amount otherwise due for the services provided, and (C) any agreed to
reduction in payment for failure to meet administrative requirements
including timely notification shall not be imposed if the patient's
insurance coverage could not be determined by the hospital after
reasonable efforts at the time the services were provided.
(3) The provisions of this subsection shall not apply to the denial of
a claim: (A) based on a reasonable belief of a corporation of fraud or
intentional misconduct resulting in misrepresentation of patient
diagnosis or the services provided, or abusive billing by a corporation;
(B) when required by a state or federal government program or coverage
that is provided by this state or a municipality thereof to its
respective employees, retirees or members; (C) that is a duplicate
claim, is a claim submitted late pursuant to subsection (g) of section
thirty-two hundred twenty-four-a of this article, or is for services for
a benefit that is not covered under the insured's contract or for a
patient determined to be ineligible for coverage; (D) except in the case
of medically necessary inpatient services resulting from an emergency
admission, where there is not an existing participating provider
agreement between such corporation and a general hospital; or (E) where
the hospital has repeatedly and systematically, over the previous twelve
month period, failed to seek prior authorization for services for which
prior authorization was required.
(4) For purposes of this subsection, an "administrative requirement"
shall not include requirements: (A) imposed on a corporation or provider
pursuant to federal or state laws, regulations or guidance; (B)
established by the state or federal government applicable to
corporations offering benefits under a state or federal government
program.
(5) The prohibition on denials set forth in this subsection shall not
apply to claims for services for which a request for preauthorization
was denied by the corporation prior to delivery of the service.
(l) A corporation organized under this article shall not require a
prior authorization determination for services provided in a neonatal
intensive care unit of a general hospital certified pursuant to article
twenty-eight of the public health law. Nothing in this subsection shall
prohibit a corporation organized under this article from denying a claim

for such services if the services are subsequently determined not
medically necessary.
(m) At least sixty days prior to the termination of a contract between
a hospital and an organization, the parties shall utilize a mutually
agreed upon mediator to assist in resolving any outstanding contractual
issues. The results of the mediation shall not be binding on the
parties.
(n) A contract between a corporation and a health care provider shall
include a provision that requires the health care provider to have in
place business processes to ensure the timely provision of provider
directory information to the corporation. A health care provider shall
submit such provider directory information to a corporation, at a
minimum, when a provider begins or terminates a network agreement with a
corporation, when there are material changes to the content of the
provider directory information of the health care provider, and at any
other time, including upon the corporation's request, as the health care
provider determines to be appropriate. For purposes of this subsection,
"provider directory information" shall include the name, address,
specialty, telephone number, and digital contact information of such
health care provider; whether the provider is accepting new patients;
for mental health and substance use disorder services providers, any
affiliations with participating facilities certified or authorized by
the office of mental health or the office of addiction services and
supports, and any restrictions regarding the availability of the
individual provider's services; and in the case of physicians, board
certification, languages spoken, and any affiliations with participating
hospitals.
(o) A contract between a corporation and a health care provider shall
include a provision that states that the provider shall reimburse the
insured for the full amount paid by the insured in excess of the
in-network cost-sharing amount, plus interest at an interest rate
determined by the superintendent in accordance with 42 U.S.C. §
300gg-139(b), for the services involved when the insured is provided
with inaccurate network status information by the corporation in a
provider directory or in response to a request that stated that the
provider was a participating provider when the provider was not a
participating provider. In the event the corporation provides inaccurate
network status information to the insured indicating the provider was a
participating provider when such provider was not a participating
provider, the corporation shall reimburse the provider for the
out-of-network services regardless of whether the insured's coverage
includes out-of-network services. Nothing in this subsection shall
prohibit a health care provider from requiring in the terms of a
contract with a corporation that the corporation remove, at the time of
termination of such contract, the provider from the corporation's
provider directory or that the corporation bear financial responsibility
for providing inaccurate network status information to an insured.