NY A00859

Insurers and health plans must grant automatic preauthorization approval to health care professionals who have received approval for at least 90% of preauthorization requests for a specific health care service during the most recent six-month evaluation period.

Insurers and health plans must complete initial evaluations and notify eligible professionals within 180 days of the law's effective date, with automatic approvals becoming effective after 225 days; annual evaluations thereafter must be completed by November 15 for January 1 effectiveness.

Health care professionals do not need to request automatic preauthorization to qualify and will receive notice within five business days of qualification, describing covered services and approval duration.

Insurers and health plans must promptly pay full claims for services covered by automatic preauthorization and cannot retroactively deny, reduce, or recoup payment except for proven fraud or failure to substantially perform the service.

Automatic preauthorizations can only be rescinded effective January each year and only if retrospective review shows less than 90% of claims met medical necessity criteria, with 30 days' notice and appeal rights to the health care professional.