(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.