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
Ldillon@ins.state.ny.us
New York Insurance Department
Is an Administrative Agency
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We have Jurisdiction over policies issued
for delivery in New York
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Can’t assist with:
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Self-funded plans
Medicare, including Medicare Advantage
Out of State contracts
Federal Employee plans
Most contractual issues
New York Insurance Department
Consumer Services Bureau
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Investigate complaints against all Department
licensees
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Insurers, HMOs, Agents, Brokers, Adjusters, Service
Contract Providers
Administer the External Appeal process
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 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 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
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 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
Health Insurance in New York
External Appeal
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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.
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.
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 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.
Health Insurance in New York
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Timely Filing of Claims
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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.
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.
Health Insurance in New York
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Adverse Reimbursement Change to a Provider
Contract
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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 termination would 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 York
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Adverse Reimbursement Change to a Provider
Contract (cont.)
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Notification is not required when:
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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.
Health Insurance in New York
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Coordination of Benefits
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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.
Health Insurance in New York
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Overpayment Recovery
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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.
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Plans must establish written policies & procedures.
State government and municipality coverage is carved out of
the 24 month look back limit.
New York Insurance Department
Questions?