NY A06937

Prohibits health plans from reversing or altering medical necessity determinations (including site of service or level of care determinations) made by utilization review agents or external appeal agents during claim audits or reviews.

Prohibits health plans from downgrading claim coding if it would reverse or alter a medical necessity determination, except for claims involving fraud, waste, or abuse.

Defines "adverse determination" to include decisions to downgrade claim coding to a lower-level service than submitted by the provider for reimbursement under both Insurance Law and Public Health Law.

Requires hospitals to have 30 days to submit medical records supporting their original claim coding after receiving adjusted payment, and requires insurers to review submissions using national coding guidelines (ICD-10, CMS, AMA standards).

Requires insurers to pay interest on increased payments resulting from hospital coding appeal submissions, computed from 30-45 days after initial claim receipt depending on transmission method.