New York A 3707: Relates to downcoding on initial review and audits reversing or altering medical necessity determinations

Bill Text

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A03707 Summary:

BILL NOA03707 

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SAME ASSAME AS S04833

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SPONSORWeprin

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COSPNSRKassay, Santabarbara, Shimsky

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MLTSPNSR

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Amd §§3224-b, 3224-a & 4900, Ins L; amd §4900, Pub Health L

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Ensures the decision to downcode an insurance claim is recognized as an adverse determination; prohibits health plans from reversing or altering medical necessity determinations made by a utilization review agent or external appeals agent as a result of an audit of claims.

Go to top A03707 Actions:

BILL NOA03707 

&nbsp

01/30/2025referred to insurance

01/07/2026referred to insurance

Go to topA03707 Committee&nbspVotes:

Go to topA03707 Floor&nbspVotes:

There are no Assembly votes for this bill in this legislative session.

Go to topA03707 Text:

 STATE OF NEW YORK
 ________________________________________________________________________

 3707

 2025-2026 Regular Sessions

 IN ASSEMBLY

 January 30, 2025
 ___________

 Introduced by M. of A. WEPRIN -- read once and referred to the Committee
 on Insurance

 AN ACT to amend the insurance law and the public health law, in relation
 to downcoding on initial review and audits reversing or altering
 medical necessity determinations

 The People of the State of New York, represented in Senate and Assem-
 bly, do enact as follows:

 1 Section 1. Paragraphs 4 and 5 of subsection (b) of section 3224-b of
 2 the insurance law are renumbered paragraphs 6 and 7 and two new para-
 3 graphs 4 and 5 are added to read as follows:
 4 (4) A review or audit of claims by or on behalf of a health plan shall
 5 not reverse or otherwise alter a medical necessity determination, which
 6 includes a site of service or level of care determination made by a
 7 utilization review agent or external appeal agent pursuant to article
 8 forty-nine of this chapter or article forty-nine of the public health
 9 law.
 10 (5) A review or audit of claims by or on behalf of a health plan shall
 11 not downgrade the coding of a claim if it has the effect of reversing or
 12 altering a medical necessity determination, which includes a site of
 13 service or level of care determination made by or on behalf of the
 14 health plan; provided however, that nothing in this paragraph shall
 15 limit a health plan's ability to review or audit claims for fraud, waste
 16 or abuse.
 17 § 2. Subsection (i) of section 3224-a of the insurance law, as amended
 18 by section 10 of part YY of chapter 56 of the laws of 2020, is amended
 19 to read as follows:
 20 (i) Except where the parties have developed a mutually agreed upon
 21 process for the reconciliation of coding disputes that includes a review
 22 of submitted medical records to ascertain the correct coding for
 23 payment, a general hospital certified pursuant to article twenty-eight
 24 of the public health law shall, upon receipt of payment of a claim for

 EXPLANATION--Matter in italics (underscored) is new; matter in brackets
 [ ] is old law to be omitted.
 LBD07475-01-5

 A. 3707 2

 1 which payment has been adjusted based on a particular coding to a
 2 patient including the assignment of diagnosis and procedure, have the
 3 opportunity to submit the affected claim with medical records supporting
 4 the hospital's initial coding of the claim within thirty days of receipt
 5 of payment. Upon receipt of such medical records, an insurer or an
 6 organization or corporation licensed or certified pursuant to article
 7 forty-three or forty-seven of this chapter or article forty-four of the
 8 public health law shall review such information to ascertain the correct
 9 coding for payment based on national coding guidelines accepted by the
 10 centers for Medicare and Medicaid services or the American medical asso-
 11 ciation, to the extent there are codes for such services, including
 12 ICD-10 guidelines to the extent available, and process the claim,
 13 including the correct coding, in accordance with the timeframes set
 14 forth in subsection (a) of this section. In the event the insurer,
 15 organization, or corporation processes the claim consistent with its
 16 initial determination, such decision shall be accompanied by a statement
 17 of the insurer, organization or corporation setting forth the specific
 18 reasons why the initial adjustment was appropriate. An insurer,