S 7470: Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstances.

  
  STATE OF NEW YORK ________________________________________________________________________ 7470 2025-2026 Regular Sessions  IN SENATE April 17, 2025 ___________ Introduced by Sens. HOYLMAN-SIGAL, CLEARE, COONEY, GALLIVAN, RIVERA, SKOUFIS, WEBB -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to requiring insurers and health plans to grant automatic preauthori- zation approvals to eligible health care professionals in certain circumstances The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (a) of section 4902 of the insurance law is 2 amended by adding a new paragraph 17 to read as follows: 3 (17) Establishment of automatic preauthorization approval requirements 4 for insurers to provide to health care professionals providing health 5 care services which shall include that: 6 (i) an insurer that uses a preauthorization process for health care 7 services shall provide an automatic preauthorization approval to a 8 health care professional for a particular health care service, as 9 defined under this title including but not limited to health care proce- 10 dures, treatments, services, pharmaceutical products, services or dura- 11 ble medical equipment if, in the most recent six-month evaluation peri- 12 od, the insurer has approved not less than ninety percent of the 13 preauthorization requests submitted by such health care professional for 14 the particular health care service. For the purposes of this require- 15 ment, a preauthorization request submitted during the evaluation period 16 shall be considered and counted as a single request and single approval 17 if the request was approved at any point between the date the request 18 was submitted by the health care professional and the final determi- 19 nation by the insurer, including any re-review or appeal process. Each 20 insurer shall complete its initial evaluation and issue its determi- 21 nation to each health care professional in its network no later than one 22 hundred eighty days after the effective date of this paragraph. The EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD01540-02-5 
 S. 7470 2 1 automatic preauthorization approval shall become effective two hundred 2 twenty-five days after the effective date of this paragraph; 3 (ii) after the initial evaluation has been completed the insurer shall 4 annually thereafter evaluate whether a health care professional quali- 5 fies for an automatic preauthorization approval under subparagraph (i) 6 of this paragraph for additional health care services. Each year, the 7 evaluation shall review preauthorization determinations made in the 8 first six months of the year. Each insurer shall issue its determination 9 to each health care professional in its network no later than November 10 fifteenth to be effective January first of the following year; 11 (iii) the insurer may continue the automatic preauthorization approval 12 under subparagraph (i) of this paragraph without evaluating whether the 13 health care professional qualifies for automatic preauthorization 14 approval for a particular evaluation period; 15 (iv) a health care professional shall not be required to request an 16 automatic preauthorization approval to qualify for such approval; 17 (v) a health care professional's automatic preauthorization approval 18 under subparagraph (i) of this paragraph shall remain in effect until 19 the thirtieth calendar day after: 20 (A) the date the insurer notifies the health care professional of the 21 insurer's determination to rescind the automatic preauthorization 22 approval pursuant to subparagraph (vii) of this paragraph if the health 23 care professional does not appeal such determination; or 24 (B) where the health care professional appeals the determination, the 25 date the insurer notifies the health care professional that an independ- 26 ent review organization has affirmed the insurer's determination to 27 rescind the automatic preauthorization approval; 28 (vi) where an insurer does not finalize a rescission determination as 29 specified in subparagraph (vii) of this paragraph, the health care 30 professional shall be considered to have met the criteria to continue to 31 qualify for the automatic preauthorization approval, which shall remain 32 in effect until the following evaluation period; 33 (vii) an insurer may rescind an automatic preauthorization approval 34 under subparagraph (i) of this paragraph only: 35 (A) effective January of each year; 36 (B) if the insurer makes a determination on the basis of a retrospec- 37 tive review as specified in subparagraph (ii) of this paragraph for the 38 most recent evaluation period that less than ninety percent of the 39 claims for the particular health care service met the medical necessity 40 criteria that would have been used by the insurer when conducting preau- 41 thorization review for the particular health care service during the 42 relevant evaluation period; and 43 (C) the insurer complies with all other applicable requirements of 44 this paragraph and the insurer notifies the health care professional not 45 less than thirty calendar days before the proposed rescission is to take 46 effect, together with the sample of claims used to make the determi- 47 nation pursuant to clause (B) of this subparagraph and a plain language 48 explanation of the health care professional's right to appeal such 49 determination and instructions on how to initiate such appeal; 50 (viii) notwithstanding any contrary provision of subparagraph (i) of 51 this paragraph, an insurer may deny an automatic preauthorization 52 approval: 53 (A) if the health care professional does not have the approval at the 54 time of the relevant evaluation period; and 55 (B) the insurer provides the health care professional with actual 56 statistics and data for the relevant preauthorization request evaluation 
 S. 7470 3 1 period and detailed information sufficient to demonstrate that the 2 health care professional does not meet the criteria for an automatic 3 preauthorization approval pursuant to subparagraph (i) of this paragraph 4 for the particular health care service; 5 (ix) after a final determination or review affirming the rescission or 6 denial of an automatic preauthorization approval for a specific health 7 care service under this paragraph, a health care professional shall be 8 eligible for consideration of such approval for the same health care 9 service after the evaluation period following the evaluation period 10 which formed the basis of the rescission or denial of such approval; 11 (x) the insurer shall, not later than five business days after deter- 12 mining that a health care professional qualifies for an automatic preau- 13 thorization approval pursuant to subparagraph (i) of this paragraph, 14 provide to a health care professional a notice that shall include: 15 (A) a statement that the health care professional qualifies for an 16 automatic preauthorization approval pursuant to this paragraph; 17 (B) a description of the health care services to which such automatic 18 preauthorization applies; and 19 (C) a statement of the duration that such automatic approval shall 20 remain in effect; 21 (xi) when the health care professional submits a preauthorization 22 request for a health care service for which the health care professional 23 qualifies for an automatic preauthorization approval under subparagraph 24 (i) of this paragraph, the insurer shall promptly issue an automatic 25 preauthorization approval for such health care service; 26 (xii) nothing in this paragraph may be construed to: 27 (A) authorize a health care professional to provide a health care 28 service outside the scope of such health care professional's applicable 29 license; or 30 (B) prohibit a health insurer from performing a retrospective review 31 of the health care service pursuant to section forty-nine hundred three 32 of this title; 33 (xiii) when a health care professional provides a health care service 34 covered by the health care professional's automatic preauthorization 35 approval, the service is deemed medically necessary by virtue of the 36 automatic preauthorization approval. For every claim submitted by a 37 health care professional for such service, each insurer shall promptly 38 pay the full payment to the health care professional. An insurer is 39 prohibited from denying, withholding, or reducing payment to a health 40 care professional for such health care service. An insurer may not 41 retroactively deny, reduce, or recoup payment from a health care profes- 42 sional for such health care service for reasons related to medical 43 necessity or appropriateness of care; 44 (xiv) an insurer may not retroactively deny, reduce, or recoup payment 45 from a health care professional for a health care service for which the 46 health care professional has qualified for an automatic preauthorization 47 approval under subparagraph (i) of this paragraph unless the insurer has 48 proven that the health care professional: 49 (A) knowingly and materially misrepresented the health care service in 50 a request for preauthorization or payment submitted to the insurer with 51 the specific intent to deceive and obtain an unlawful payment from the 52 insurer; or 53 (B) failed to substantially perform the health care service; 54 (xv) an insurer may not retroactively deny, reduce or recoup payment 55 from a health care professional for a health care service for which the 56 health care professional has qualified for an automatic preauthorization 
 S. 7470 4 1 approval solely on the basis of the rescission of the health care 2 professional's automatic preauthorization approval. Nothing herein shall 3 limit a health care professional's ability to file a complaint with the 4 department; 5 (xvi) the insurer shall make available and submit to the superinten- 6 dent, at the superintendent's request, documentation that describes the 7 insurer's process for: 8 (A) determining the specific health care service or services for which 9 an individual health care professional is granted an automatic preau- 10 thorization approval; and 11 (B) any other activity, policy, decision, or determination related to 12 automatic preauthorization approvals; and 13 (xvii) the superintendent shall promulgate regulations to implement 14 the requirements of this section and establish additional minimum stand- 15 ards as appropriate. 16 § 2. Subdivision 1 of section 4902 of the public health law is amended 17 by adding a new paragraph (m) to read as follows: 18 (m) Establishment of automatic preauthorization approval requirements 19 for health care plans to provide to health care professionals providing 20 certain health care services which shall include that: 21 (i) a health care plan that uses a preauthorization process for health 22 care services shall provide an automatic preauthorization approval to a 23 health care professional for a particular health care service if, as 24 defined under this title including but not limited to health care proce- 25 dures, treatments, services, pharmaceutical products, services or dura- 26 ble medical equipment, in the most recent six-month evaluation period, 27 the health care plan has approved not less than ninety percent of the 28 preauthorization requests submitted by such health care professional for 29 the particular health care service. For the purposes of this require- 30 ment, a preauthorization request submitted during the evaluation period 31 shall be considered and counted as a single request and single approval 32 if the request was approved at any point between the date the request 33 was submitted by the health care professional and the final determi- 34 nation by the health care plan, including any re-review or appeal proc- 35 ess. Each insurer shall complete its initial evaluation and issue its 36 determination to each health care professional in its network no later 37 than one hundred eighty days after the effective date of this paragraph. 38 The automatic preauthorization approval shall become effective two 39 hundred twenty-five days after the effective date of this paragraph; 40 (ii) after the initial evaluation has been completed the health care 41 plan shall annually thereafter evaluate whether a health care profes- 42 sional qualifies for an automatic preauthorization approval under 43 subparagraph (i) of this paragraph for additional health care services. 44 Each year, the evaluation shall review preauthorization determinations 45 made in the first six months of the year. Each health care plan shall 46 issue its determination to each health care professional in its network 47 no later than November fifteenth to be effective January first of the 48 following year; 49 (iii) the health care plan may continue the automatic preauthorization 50 approval under subparagraph (i) of this paragraph without evaluating 51 whether the health care professional qualifies for the automatic preau- 52 thorization approval for a particular evaluation period; 53 (iv) a health care professional shall not be required to request an 54 automatic preauthorization approval to qualify for such approval; 
 S. 7470 5 1 (v) a health care professional's automatic preauthorization approval 2 under subparagraph (i) of this paragraph shall remain in effect until 3 the thirtieth calendar day after: 4 (A) the date the health care plan notifies the health care profes- 5 sional of the health care plan's determination to rescind the automatic 6 preauthorization approval pursuant to subparagraph (vii) of this para- 7 graph if the health care professional does not appeal such determi- 8 nation; or 9 (B) where the health care professional appeals the determination, the 10 date the health care plan notifies the health care professional that an 11 independent review organization has affirmed the health care plan's 12 determination to rescind the automatic preauthorization approval; 13 (vi) where a health care plan does not finalize a rescission determi- 14 nation as specified in subparagraph (vii) of this paragraph, the health 15 care professional shall be considered to have met the criteria to 16 continue to qualify for the automatic preauthorization approval, which 17 shall remain in effect until the following evaluation period; 18 (vii) a health care plan may rescind an exemption from preauthori- 19 zation requirements under subparagraph (i) of this paragraph only: 20 (A) effective January each year; 21 (B) if the health care plan makes a determination on the basis of a 22 retrospective review as specified in subparagraph (ii) of this paragraph 23 for the most recent evaluation period that less than ninety percent of 24 the claims for the particular health care service met the medical neces- 25 sity criteria that would have been used by the health care plan when 26 conducting preauthorization review for the particular health care 27 service during the relevant evaluation period; and 28 (C) the health care plan complies with all other applicable require- 29 ments of this paragraph and the health care plan notifies the health 30 care professional not less than thirty calendar days before the proposed 31 rescission is to take effect, together with the sample of claims used to 32 make the determination pursuant to clause (B) of this subparagraph and a 33 plain language explanation of the health care professional's right to 34 appeal such determination and instructions on how to initiate such 35 appeal; 36 (viii) notwithstanding any contrary provision of subparagraph (i) of 37 this paragraph, a health care plan may deny an automatic preauthori- 38 zation approval: 39 (A) if the health care professional does not have the approval at the 40 time of the relevant evaluation period; and 41 (B) the health care plan provides the health care professional with 42 actual statistics and data for the relevant preauthorization request 43 evaluation period and detailed information sufficient to demonstrate 44 that the health care professional does not meet the criteria for an 45 automatic preauthorization approval pursuant to subparagraph (i) of this 46 paragraph for the particular health care service; 47 (ix) after a final determination or review affirming the rescission or 48 denial of an automatic preauthorization approval for a specific health 49 care service under this paragraph, a health care professional shall be 50 eligible for consideration of such approval for the same health care 51 service after the evaluation period following the evaluation period 52 which formed the basis of the rescission or denial of such approval; 53 (x) the health care plan shall, not later than five business days 54 after determining that a health care professional qualifies for an auto- 55 matic preauthorization approval pursuant to subparagraph (i) of this 
 S. 7470 6 1 paragraph, provide to a health care professional a notice that shall 2 include: 3 (A) a statement that the health care professional qualifies for an 4 automatic preauthorization approval pursuant to this paragraph; 5 (B) a description of the health care services to which such automatic 6 preauthorization approval applies; and 7 (C) a statement of the duration that such automatic approval shall 8 remain in effect; 9 (xi) when the health care professional submits a preauthorization 10 request for a health care service for which the health care professional 11 qualifies for an automatic preauthorization approval under subparagraph 12 (i) of this paragraph, the health care plan shall promptly issue an 13 automatic preauthorization approval for such health care service; 14 (xii) nothing in this paragraph shall be construed to: 15 (A) authorize a health care professional to provide a health care 16 service outside the scope of such health care professional's applicable 17 license; or 18 (B) prohibit a health care plan from performing a retrospective review 19 of the health care service pursuant to section forty-nine hundred three 20 of this title; 21 (xiii) when a health care professional provides a health care service 22 covered by the health care professional's automatic preauthorization 23 approval, the service is deemed medically necessary by virtue of the 24 automatic preauthorization approval. For every claim submitted by a 25 health care professional for such service, each health care plan shall 26 promptly pay the full payment to the health care professional. A health 27 care plan is prohibited from denying, withholding, or reducing payment 28 to a health care professional for such health care service. A health 29 care plan may not retroactively deny, reduce, or recoup payment from a 30 health care professional for such health care service for reasons 31 related to medical necessity or appropriateness of care; 32 (xiv) a health care plan may not retroactively deny, reduce, or recoup 33 payment from a health care professional for a health care service for 34 which the health care professional has qualified for an automatic preau- 35 thorization approval under subparagraph (i) of this paragraph unless the 36 health care plan has proven that the health care professional: 37 (A) knowingly and materially misrepresented the health care service in 38 a request for preauthorization or payment submitted to the health care 39 plan with the specific intent to deceive and obtain an unlawful payment 40 from the health care plan; or 41 (B) failed to substantially perform the health care service; 42 (xv) a health care plan may not retroactively deny, reduce or recoup 43 payment from a health care professional for a health care service for 44 which the health care professional has qualified for an automatic preau- 45 thorization approval solely on the basis of the rescission of the health 46 care professional's automatic preauthorization approval. Nothing herein 47 shall limit a health care professional's ability to file a complaint 48 with the department; 49 (xvi) the health care plan shall make available and submit to the 50 commissioner, at the commissioner's request, documentation that 51 describes the health care plan's process for: 52 (A) determining the specific health care service or services for which 53 an individual health care professional is granted an automatic preau- 54 thorization approval; and 55 (B) any other activity, policy, decision, or determination related to 56 automatic preauthorization approvals; and 
 S. 7470 7 1 (xvii) the commissioner, in consultation with the superintendent, 2 shall promulgate regulations to implement the requirements of this 3 section and establish additional minimum standards as appropriate. 4 § 3. This act shall take effect on the one hundred eightieth day after 5 it shall have become a law.