BILL NUMBER: S3402
SPONSOR: BRESLIN
 
TITLE OF BILL:
An act to amend the public health law and the insurance law, in relation
to providing that the failure by the utilization review agent to make a
determination within certain time periods shall be deemed to be an
approval of the health care services
 
PURPOSE OR GENERAL IDEA OF BILL:
This purpose of this bill is to ensure timely determinations by health
plans regarding the provision of healthcare services, which would miti-
gate potential delays in patient care.
 
SUMMARY OF SPECIFIC PROVISIONS:
This bill would amend subdivision 7 of section 4903 of the public health
law and subsection (g) of section 4903 of the insurance law to provide
that failure by a utilization review agent to make a determination with-
in required time periods would be deemed to be an approval of the health
care service in question.
 
JUSTIFICATION:
Under current law, when a healthcare provider submits a request for
services for a health plan's enrollee, a lack of response from the
health plan results in a denial. This requires healthcare providers to
engage in a cumbersome process to appeal the denial and receive the
payment rightfully owed to the provider. Treating a non-response from a
health plan as a denial rather than as an approval, wrongly shifts the
burden to providers and forces them to appeal from silence. Notably,
after potentially lengthy and costly reviews and delays, the result is
routinely the validation of services.
Additionally, there are established timeframes within which utilization
review determinations must be made. Allowing plans to deny services by
simply not making a determination within the required timeframes creates
an incentive for insurers to delay or ignore requests. Failure of a plan
to respond to a timely claim submission should be treated as an
approval, rather than a denial. This bill would help to ensure utiliza-
tion review determinations are made in a timely manner, and would reduce
potential delays in treatment that can result in unnecessary negative
consequences in patient care.
 
PRIOR LEGISLATIVE HISTORY:
2021-22: S6920
 
FISCAL IMPLICATIONS:
None.
 
EFFECTIVE DATE:
This act shall take effect on the thirtieth day after it shall have
become a law.

Statutes affected:
S3402: 4903 public health law, 4903(7) public health law, 4903 insurance law, 4903(g) insurance law