Health insurance in new york
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Health Insurance in New York. Laura Dillon, Principal Examiner New York Insurance Department Consumer Services Bureau One Commerce Plaza Albany NY 12257 (518) 486-9105 [email protected] New York Insurance Department. Is an Administrative Agency

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Health Insurance in New York

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Health insurance in new york

Health Insurance in New York

Laura Dillon, Principal Examiner

New York Insurance Department

Consumer Services Bureau

One Commerce Plaza

Albany NY 12257

(518) 486-9105

[email protected]


New york insurance department

New York Insurance Department

Is an Administrative Agency

  • We have Jurisdiction over policies issued for delivery in New York

    • Can’t assist with:

      • Self-funded plans

      • Medicare, including Medicare Advantage

      • Out of State contracts

      • Federal Employee plans

      • Most contractual issues


New york insurance department1

New York Insurance Department

Consumer Services Bureau

  • Investigate complaints against all Department licensees

    • Insurers, HMOs, Agents, Brokers, Adjusters, Service Contract Providers

  • Administer the External Appeal process


Health insurance in new york1

Health Insurance in New York

  • NY Insurance Law requires insurers and HMOs to provide specific mandated benefits

    • Such as maternity care, 2nd opinion for cancer diagnosis, screening for certain cancers, well child care, diabetic supplies, infertility and certain screening tests.

    • Coverage is subject to Utilization Review (Medical Necessity) where appropriate.


Health insurance in new york2

Health Insurance in New York

Prompt Pay Law

  • Claims must be processed within specific time frames after receipt by the insurer/HMO

    • Claims must be paid:

      • Within 45 days if submitted on paper, or

      • Within 30 days if submitted via electronic means, or

    • Denied within 30 days of receipt, or

    • Request additional information within 30 days of receipt.

      • Request must be in writing and must include all necessary information


Health insurance in new york3

Health Insurance in New York

Prompt Pay Law (cont.)

  • Clean Claim (obligation to pay must be reasonably clear)

    • Regulation 178 (paper claims)

  • Fraudulent claims

    • Reasonable basis to suspect fraud

      • Don’t have to comply with time frames


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Health Insurance in New York

Prompt Pay Law (cont.)

  • Interest

    • 12% simple interest

    • Begins to accrue the day the claim payment is due

    • Not applicable to PIP payments or deductibles

    • Is applicable to adjusted claims, if health plan made an error (amount of additional payment)


Health insurance in new york5

Health Insurance in New York

Prompt Pay Monetary Penalties

  • Each late claim is a separate violation

    • 1st time Department can fine for individual violations

  • Based on closed complaints

  • Collected over $10 million in fines since law became effective


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Health Insurance in New York

External Appeal

  • Review by a neutral medical professional for denials based on lack of medical necessity or experimental/investigational services.

  • Must request one level of internal appeal after initial denial.

  • Must file external appeal application within 45 days of FAD.

  • Decision is binding on insurer/HMO.

  • Member/patient is always permitted to appeal.

  • Providers can appeal retrospective and concurrent denials.


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Health Insurance in New York

  • Changes to External Appeal include:

    • Right for providers to appeal concurrent denials.

      • Loser pays.

      • Hold harmless provision.

    • Department has the right to confirm the designee.


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Health Insurance in New York

Contractual Issues

  • Provider responsibilities (participating)

    • Know contractual requirements

      • Time frames

      • approval/pre-certification requirements

    • Know applicable laws

      • Sections 3217-b and 4325 of the New York Insurance Law

    • Post Payments timely

    • Make applicable adjustments to patient account


Health insurance in new york9

Health Insurance in New York

Contractual Issues (cont.)

  • Beware of requesting special handling for certain types of services.

    • Technology limits can cause problems with the processing of these claims.


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Health Insurance in New York

  • Timely Filing of Claims

    • 120 days after date of service for claims submitted by providers and subscribers.

    • Contract may provide more time but cannot be less than 120 days.

    • Medicaid Managed Care shall not be less than 90 days.


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Health Insurance in New York

  • Timely Filing of Claims (cont.)

    • Reconsideration process for participating providers

      • Insurer or HMO shall pay the claim if the provider can demonstrate both:

        • The late filing was the result of an unusual occurrence, and

        • The provider has a pattern or practice of timely filing.

      • If demonstrated the insurer MAY impose a 25% penalty.

      • In no case will a claim be considered more than 365 days after the date of service.


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Health Insurance in New York

  • Adverse Reimbursement Change to a Provider Contract

    • Insurers must provide at least 90 days advance written notice to contracted providers of an adverse reimbursement change.

    • Within 30 days of the notice, the provider may terminate their participation agreement by giving written notice.

    • Such terminationwould be effective upon the implementation date of the change.

    • “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


Health insurance in new york13

Health Insurance in New York

  • Adverse Reimbursement Change to a Provider Contract (cont.)

    • Notification is not required when:

      • The change is otherwise required by law or is the result of changes in payment policies established by a government agency or by the AMA current CPT guidelines, or

      • Such change is expressly provided for under the terms of the contract by inclusion or reference to a specific fee or fee schedule, reimbursement methodology or payment policy.


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Health Insurance in New York

  • Coordination of Benefits

    • Section 3224-c prohibits the denial of a claim, in whole or in part, on the basis that another insurers is liable unless there is a reasonable basis to believe another carrier is primary.

    • Permits an insurer or HMO to send a COB questionnaire, however if no information is received within 45 days, the claim must be adjudicated. The claim can’t be denied based solely on the insurer not receiving a response to the questionnaire.

    • COB Regulation 178 (Part 217 – Subpart 2) sets forth rules about coordinating benefits in those cases where the insurer has a basis to believe they are not primary.


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Health Insurance in New York

  • Overpayment Recovery

    • Section 3224-b expands the overpayment recovery requirements to facilities.

    • 30 day advance written notice is required before recoupment of overpayment

    • Insurers cannot go back more than 24 months unless suspicion of fraud or abusive billing.

    • Requires that providers be given an opportunity to challenge the recovery request.

      • Plans must establish written policies & procedures.

    • State government and municipality coverage is carved out of the 24 month look back limit.


New york insurance department2

New York Insurance Department

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