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§3224-a
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§3224-a . Standards for prompt, fair and equitable settlement of claims for health care and payments for health care services. In the processing of all health care claims submitted under contracts or agreements issued or entered into pursuant to articles 32, 42 and 43 of this chapter and article 44 of the public health law and all bills for health care services rendered by health care providers pursuant to such contracts or agreements, any insurer or organization or corporation licensed or certified pursuant to article 43 of this chapter or article 44 of the public health law shall adhere to the following standards:
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§3224-a(a)
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(a) Except in a case where the obligation of an insurer or an organization or corporation licensed or certified pursuant to article 43 of this chapter or article 44 of the public health law to pay a claim submitted by a policyholder or person covered under such policy or make a payment to a health care provider is not reasonably clear, or when there is a reasonable basis supported by specific information available for review by the superintendent that such claim or bill for health care services rendered was submitted fraudulently, such insurer or organization or corporation shall pay the claim to a policyholder or covered person or make a payment to a health care provider within 45 days of receipt of a claim or bill for services rendered.
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§3224-a(b)
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(b) In a case where the obligation of an insurer or an organization or corporation licensed or certified pursuant to article 43 of this chapter or article 44 of the public health law to pay a claim or make a payment for health care services rendered is not reasonably clear due to a good faith dispute regarding the eligibility of a person for coverage, the liability of another insurer or corporation or organization for all or part of the claim, the amount of the claim, the benefits covered under a contract or agreement, or the manner in which services were accessed or provided, an insurer or organization or corporation shall pay any undisputed portion of the claim in accordance with (this sub§) and notify the policyholder, covered person or health care provider in writing within 30 calendar days of the receipt of the claim:
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§3224-a(b)(1)
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(1) that it is not obligated to pay the claim or make the medical payment, stating the specific reasons why it is not liable; or
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§3224-a(b)(2)
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(2) to request all additional information needed to determine liability to pay the claim or make the health care payment. Upon receipt of the information requested in paragraph (this sub§)(2) or an appeal of a claim or bill for health care services denied pursuant to paragraph (this sub§)(1) ,an insurer or organization or corporation licensed pursuant to article 43 of this chapter or article 44 of the public health law shall comply with subsection (this §)(a) .
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§3224-a(c)
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(c) Each claim or bill for health care services processed in violation of (this §) shall constitute a separate violation. In addition to the penalties provided in this chapter, any insurer or organization or corporation that fails to adhere to the standards contained in (this §) shall be obligated to pay to the health care provider or person submitting the claim, in full settlement of the claim or bill for health care services, the amount of the claim or health care payment plus interest on the amount of such claim or health care payment of the greater of the rate equal to the rate set by the commissioner of taxation and finance for corporate taxes pursuant to paragraph §1096(e)(1) of the tax law or 12% per annum, to be computed from the date the claim or health care payment was required to be made. When the amount of interest due on such a claim is less then $2.00, and insurer or organization or corporation shall not be required to pay interest on such claim.
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§3224-a(d)
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(d) For the purposes of (this §) :
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§3224-a(d)(1)
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(1) "policyholder" shall mean a person covered under such policy or a representative designated by such person; and
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§3224-a(d)(2)
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(2) "health care provider" shall mean an entity licensed or certified pursuant to article 28, 36 or 40 of the public health law, a facility licensed pursuant to article 19, 23 or 31 of the mental hygiene law, a health care professional licensed, registered or certified pursuant to title 8 of the education law, a dispenser or provider of pharmaceutical products, services or durable medical equipment, or a representative designated by such entity or person.
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§3224-a(e)
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(e) Nothing in (this §) shall in any way be deemed to impair any right available to the state to adjust the timing of its payments for medical assistance pursuant to title 11 of article 5 of the social services law, or for child health insurance plan benefits pursuant to title 1- a article 25 of the public health law or otherwise be deemed to require adjustment of payments by the state for such medical assistance or child health insurance.
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§3224-a(f)
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(f) In any action brought by the superintendent pursuant to (this §) or article 24 of this chapter relating to (this §) regarding payments for medical assistance pursuant to title 11 of article 5 of the social services law, child health insurance plan benefits pursuant to title 1- a article 25 of the public health law, benefits under the voucher insurance program pursuant to §1121 of this chapter, and benefits under the New York state small business health insurance partnership program pursuant to article 9- A the public health law, it shall be a mitigating factor that the insurer, corporation or organization is owed any premium amounts, premium adjustments, stop-loss recoveries or other payments from the state or 1 of its fiscal intermediaries under any such program. Source Data downloaded: 2009-04-19 12: 25: 15; Processed: 2009-05-08 15: 36: 01
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