Section 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. An
  insurer  shall  complete  review  of  the  health  care   professional's
  application  to  participate  in the in-network portion of the insurer's
  network  and,  within  ninety  days   of   receiving   a   health   care
  professional's  completed  application  to  participate in the insurer's
  network, will 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 insurer'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, an insurer shall make every effort to obtain
  such information as soon as possible.
    * NB Effective until October 1, 2009
    * (a)  (1)  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. An insurer  shall  complete  review  of  the  health  care
  professional's  application  to participate in the in-network portion of
  the insurer's network and, within ninety days of receiving a health care
  professional's completed application to  participate  in  the  insurer's
  network,  will notify the health care professional as to: (A) whether he
  or she is credentialed; or (B) whether additional time is  necessary  to
  make  a  determination in spite of the insurer'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, an insurer shall make every effort to obtain
  such information as soon as possible.
    (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 ninety days 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 ninetieth
  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.
    * NB Effective October 1, 2009
    (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.