NY S08299

Health care professionals are exempt from preauthorization requirements if their insurer or health care plan approved at least 90 percent of their preauthorization requests during the most recent six-month evaluation period.

Insurers and health care plans must evaluate exemption eligibility every six months, and professionals automatically qualify without having to request an exemption.

Insurers and health care plans may only rescind an exemption during January or June each year, and only based on retrospective review of a random sample of 5-20 claims showing less than 90 percent met medical necessity criteria, with at least 20 days' notice to the professional.

Health care professionals may appeal exemption rescissions or denials to an independent review organization, and must be notified within five days of qualifying for an exemption and informed of its duration.

The bill does not authorize professionals to provide services outside their license scope and does not prohibit retrospective review of health care services by insurers or health care plans.