NY A03707

Prohibits health plan claim reviews or audits from reversing or altering medical necessity determinations, including site of service or level of care decisions, previously made by utilization review agents or external appeal agents

Bars health plans from downcoding claims if it would effectively reverse or alter a prior medical necessity determination, though plans retain the ability to review claims for fraud, waste, or abuse

Expands the legal definition of "adverse determination" in both the Insurance Law and Public Health Law to include decisions that downgrade claim coding to a lower-level service than submitted by the provider

Removes existing language that exempted coding determinations from being classified as adverse determinations, thereby granting providers appeal rights for downcoded claims

Requires insurers reviewing disputed hospital coding to follow national coding guidelines from CMS or the American Medical Association, including ICD-10 guidelines when available