NY A08172

Requires insurers to pay hospital claims at contracted rates within established timeframes, regardless of medical necessity reviews, preauthorization requirements, or documentation policies

Allows payors to request clinical documentation for post-payment review within 90 days of payment, but limits requests to no more than 10% of claims paid since the last joint committee meeting (can increase to 15% if over 50% of reviewed claims were inappropriately billed)

Establishes a joint committee composed of equal numbers of medical directors/clinicians from both the payor and hospital to conduct quarterly post-payment reviews of disputed claims

Mandates that unresolved disputes between the joint committee be forwarded to a mutually agreed upon independent third-party review agent for binding determination

Requires hospitals to refund payors within 30 days if services are determined not medically necessary, while prohibiting hospitals from billing patients (except copays, coinsurance, or deductibles) for services deemed unnecessary

Takes effect January 1, 2026