NYSSOS supports A3789A/S7297A, which requires insurers to use evidence-based, peer-reviewed clinical guidelines when reviewing treatment requests. This means fewer inappropriate denials and quicker access to surgeries, imaging, and physical therapy.
Orthopedic conditions often require prompt evaluation and treatment to prevent worsening of symptoms or complications. Overall, this bill aims to enhance the standards and processes related to utilization review programs and pre-authorization of health care services in New York State, with the goal of ensuring timely access to necessary medical treatments while maintaining appropriate oversight and standards.
Key provisions of this bill (A3789A/S7297A) include:
Utilization Review Program Standards: The bill requires that utilization review programs utilize recognized evidence-based and peer-reviewed clinical review criteria that consider the needs of typical patient populations and diagnoses. This ensures that the criteria used for reviewing health care services are based on established medical evidence and are relevant to patient needs.
Pre-authorization of Health Care Services: It sets specific timeframes for utilization review determinations involving health care services that require pre-authorization. For instance, determinations must be made within seventy-two hours of receiving necessary information, or within twenty-four hours if the health of the insured is in serious jeopardy without the recommended services. Additionally, approvals for pre-authorization are deemed valid for the duration of the prescription or treatment requested.
Claim Payment: The bill mandates that insurers, health maintenance organizations, and other relevant organizations pay claims for health care services that were pre-authorized and for which eligibility was confirmed on the day of the service, subject to certain conditions. These conditions include timely submission of claims, exhaustion of benefit limitations, accuracy of information provided, and absence of fraud or abuse.