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should be mandated when a liability form is used. The standardized form and language should notinclude unlimited financial liability language when impermissible.Topics Considered by the Workgroup in Addition to those Specifically Referenced in Law1. Facility Fees. Prior to rendering services, providers charging facility fees should disclose thatfacility fees will be charged by that provider and in what amount. Facility fees should not becharged when an office visit is for a preventive service for which cost-sharing is prohibited.2. Uniform Hospital Billing. DOH should continue discussions with stakeholders to explore ways tomake billing easier for consumers to understand.3. Notification of Hospital Admissions. Providers should notify health plans of hospital admissions,discharges, or transfers within 24 hours, or one business day if the admission, discharge, or transferoccurs on a weekend and health plan staff are unavailable, as a best practice in order to facilitatedischarge planning and care coordination.4. Claim Deadlines, Duplicate Claims, and Accounts Receivable. Health plans and hospitalsshould work collaboratively to develop standard terms, definitions, and methodologies to improvecommunication and reduce friction around claims activity.5. Health Care Claims Reports. The draft template health care claims report, which must becompleted by health plans and submitted to DFS starting in 2022, should be finalized in a timelymanner.9

INTRODUCTIONThe 2020 enacted Executive budget directed DFS, in conjunction with DOH, to convene aHealth Care Administrative Simplification Workgroup to study and evaluate mechanisms to reducehealth care administration costs and complexities through standardization, simplification, andtechnology. A diverse group of health care industry leaders representing consumers, hospitals,physicians, behavioral health providers, health insurers, insurance brokers, and unions served asWorkgroup members. The Workgroup was required to consider: provider credentialing;preauthorization practices; access to electronic medical records; claim submission and payment; claimattachments; and insurance eligibility verification. Additional topics were discussed, including facilityfees, notification of hospital admissions, claim deadlines, health care claims reports, and utilizationreview. The first meeting of the Workgroup was held on November 3, 2020, and the Workgroup metregularly over a ten-month period. This report describes the discussions and recommendations of theWorkgroup.THE HEALTH CARE ADMINISTRATIVE SIMPLIFICATION WORKGROUPDISCUSSIONSProvider CredentialingBackgroundCredentialing is the process used by health plans to assess and verify the qualifications of ahealth care provider (including Primary Source Verification of the provider’s state licensure, boardcertification, education and training, residency/fellowship programs, and malpractice history) todetermine whether the provider should be added to a plan’s network. The Insurance Law and PublicHealth Law set forth requirements and timeframes for the credentialing process, which begins when a10

health care professional completes a credentialing application and submits it to a health plan.4 Within60 days of receipt of a complete credentialing application, the law requires a health plan to review theapplication and notify the health care professional whether they are credentialed or whether additionaltime is needed because of a failure by a third party to provide necessary documentation. A health planmust make every effort to obtain the documentation and make a final determination within 21 days ofreceipt of the documentation. If a health plan does not approve or deny a completed application within60 days of receipt, a health care professional (either newly-licensed or recently relocated to New YorkState) in a group practice must be deemed “provisionally credentialed” and may participate in thehealth plan’s network. However, if the health care professional’s application is ultimately denied, thehealth care professional’s group practice must agree to refund any payments that were made for innetwork services provided by the provisionally credentialed health care professional and only collectthe in-network cost-sharing from the insured. In addition, a health plan must provisionally credential anewly-licensed physician, a physician who has recently relocated to New York State, or a physicianwho has changed their corporate relationship and becomes employed by a hospital or a facility uponreceipt of the hospital’s and physician's completed sections of a credentialing application, as well asnotification that the physician has been granted hospital privileges. Again, if the physician is notultimately credentialed, the health plan is not required to pay in-network benefits and the insured mustbe held harmless.Credentialing ProcessA significant issue raised by provider Workgroup members is that the credentialingtimeframes and requirements in the Insurance Law and Public Health Law only apply to healthmaintenance organizations (HMOs) and a very narrow category of health insurance policies (managed4Insurance Law § 4803 and Public Health Law § 4406-d. A health care professional is someone who is licensed,registered, or certified pursuant to Education Law Title 8.11

care products). In addition, the credentialing timeframes only apply to applications submitted byhealth care professionals and not to applications submitted by facilities.The Workgroup recommends that the Insurance Law be amended to apply the credentialingtimeframes and requirements to all comprehensive health insurance policies with provider networks.5In addition, the Workgroup recommends that the Insurance Law and Public Health Law be amended toextend the credentialing timeframes to include facility applications.Credentialing ApplicationWorkgroup members representing providers expressed concern regarding credentialingapplications and a lack of uniformity in related requests for information. These Workgroup membersnoted that health plans typically use a credentialing application provided by CAQH, which is anational, non-profit organization focused on streamlining the business of health care. However, healthplans frequently ask questions and request information from providers, in addition to those in theCAQH application form, including to address state Medicaid requirements or to obtain detailedmalpractice history, which may vary among the plans. Additionally, Workgroup membersrepresenting providers and facilities noted that some plans collect information with the initialapplication that would also be collected and verified during the Primary Source Verification process,which is unnecessary and burdensome. Workgroup members also noted that the CAQH application isdesigned for health care professionals and cannot be used for facility credentialing because it does notcollect all necessary information such as ownership, staffing, or site inspection history.The Workgroup recommends the continued use of the CAQH standard application for healthcare professional credentialing. Further, the Workgroup recommends that health plans develop astandard, simplified list of additional questions, as well as identify any follow-up information requeststhat can be standardized or use standardized formats to obtain any follow-up information.5Insurance Law § 4803.12

Status of Credentialing ApplicationsWorkgroup members representing providers stated that it is difficult to check on the status of acredentialing application after it is submitted to a health plan. Health plans stated that many planscurrently operate dedicated telephone hotlines or online portals for providers to request status reportsor have real-time communications. However, providers noted that some telephone hotlines or onlineportals do not provide meaningful information as to when credentialing will be completed. TheWorkgroup recommends that health plans implement an online portal or telephone hotline to provideeffective, real-time information and meaningful status updates for providers. Specifically, the onlineportal or telephone hotline should be able to identify missing information from the provider’scredentialing application and the status of the application in the health plan’s review process.Completion of Credentialing ApplicationsWorkgroup members noted that the back and forth required to obtain necessary informationduring the credentialing process is time consuming. Workgroup members representing health plansnoted that providers often submit incomplete applications, requiring the plan to reach out to theprovider to obtain the necessary information for a complete application. The Workgroup recommendsthat providers ensure that their applications are complete, review their information recorded in theCAQH database to make sure that it is up to date, and provide timely responses to requests foradditional or missing information. Additionally, Workgroup members representing providers notedthat health plans frequently request information that will be verified during the Primary SourceVerification process. The Workgroup recommends that health plans review their Primary SourceVerification processes to ensure that the health plan is not collecting duplicative information.Credentialing DatabaseWorkgroup members discussed the possibility of creating a centralized credentialing databaseto simplify the credentialing process. The database would contain the information needed to credentiala provider. Workgroup members recommend that plans and providers collaborate to explore the13

feasibility of an independent, centralized credentialing database, including the scope, functions, andoverall parameters of the database.Provisional CredentialingWorkgroup members discussed whether to expand provisional credentialing, which enables anewly-licensed or recently relocated physician joining a group practice or employed by a hospital to beconsidered an in-network provider before being fully credentialed by a health plan. It was noted byWorkgroup members representing health plans that provisional credentialing is not frequently used.Workgroup members representing providers pointed out that infrequent use of provisionalcredentialing may be due to the limited application of the Insurance Law provisions regardingcredentialing. Workgroup members noted that if improvements on other aspects of the credentialingprocess reduce credentialing timeframes, expansion of provisional credentialing may be unnecessary.Workgroup members representing consumers expressed concern that a provider might have a historyof malpractice or other misconduct that would not be revealed prior to provisional credentialing. TheWorkgroup did not reach a consensus on this issue.Facility CredentialingWorkgroup members representing facilities noted that credentialing applications for facilitiesare not uniform and that the CAQH application is not workable for facility credentialing. DFSsurveyed Workgroup members to obtain sample facility credentialing applications to determine thefeasibility of creating a standard application for facility credentialing. DFS created a draft standardfacility credentialing application and sent it to Workgroup members for feedback. The Workgrouprecommends continued collaboration on creating a standardized credentialing application that will beused for facilities.Workgroup members representing facilities also noted that during the re-credentialing process,facility credentialing applications are not pre-populated with information from a previous credentialingapplication. These Workgroup members found it time-consuming to re-enter this information during14

re-credentialing. Facilities also expressed concern that different facility sites are credentialed atdifferent times and suggested that health plans provide an option for all sites affiliated with the facilityto be credentialed at the same time. Workgroup members representing health plans noted that somehealth plans currently re-credential all affiliated sites at the same time. The Workgroup recommendsthat health plans pre-populate re-credentialing applications for facilities, with facilities updating anyincorrect or incomplete information, as opposed to facilities having to complete a new application eachtime the facility is re-credentialed, and that facilities provide complete and timely responses. TheWorkgroup also recommends that health plans work with facilities to re-credential all affiliated sites atthe same time if requested by a facility.Preauthorization PracticesBackgroundPreauthorization is a review that is conducted by a health plan or its utilization review agent todetermine whether a service is medically necessary before the service is provided to an insured.Preauthorization is permitted under Insurance Law and Public Health Law Articles 49, except foremergency services and certain mental health and substance use disorder treatments, and subject tocertain timeframes and requirements. When conducting preauthorization, health plans and theirutilization review agents typically use evidence-based and peer reviewed clinical review criteria, whichare a set of standards used to determine whether a health care service or treatment is medicallynecessary. The Insurance Law and Public Health Law require health plans to disclose the writtenclinical review criteria relating to a particular condition or disease upon written request of an insured,prospective insured, or the insured’s health care provider.6 Additionally, when a health plan orutilization review agent makes an adverse determination, it must state that the clinical review criteria6Insurance Law §§ 3217-a(b)(10) and 4324(b)(10) and Public Health Law § 4408(2)(j).15

relied upon to make the determination is available upon request of the insured or the insured’sdesignee.Disclosure and Timeframe to Provide Clinical Review CriteriaWorkgroup members representing consumers explained that access to clinical review criteriahelps insureds and providers understand what information should be provided for the service to beapproved and whether an appeal should be pursued, ideally leading to fewer denials and less need forappeals. Workgroup members representing consumers expressed concern that health plans and theirutilization review agents do not provide timely access to their clinical review criteria and would likethe clinical review criteria to be provided within one day for expedited cases. DFS remindedWorkgroup members that health plans are responsible for providing clinical criteria used by theirdelegated utilization review agents. Workgroup members representing health plans stated that it is acommon practice of health plans to post clinical review criteria on their websites. However,Workgroup members representing consumers noted that clinical review criteria are often only availablein “locked” areas of a plan’s website and therefore accessible only to an insured who has logged intothe plan’s website, making it difficult for authorized representatives and insureds who are not techsavvy to access the information.The Workgroup recommends that health plans post their clinical review criteria, includingcriteria used by delegated utilization review agents, in a centralized place on their websites that isreadily available to the public. If any information in the clinical review criteria is consideredproprietary by a third party, health plans should create an online process to request the clinical reviewcriteria. In addition, the Workgroup recommends that health plans and their delegated utilizationreview agents provide the requested clinical review criteria within five days of receiving such requestsfrom an insured or their authorized representative. If the request involves an expedited appeal, thehealth plan and their delegated utilization review agents should provide the clinical review criteriawithin a shorter time period.16

Additionally, Workgroup members representing consumers stated that some health plans takeweeks to process patient authorization forms. During this time, advocates and family members canonly speak to the health plan with the insured on the call. This is not feasible for many people who arereceiving inpatient treatment, where they do not have access to phones, or who are experiencing amental health or substance use crisis. Workgroup members representing consumers recommend thathealth plans be required to accept a standard form for insureds to designate an authorizedrepresentative and that health plans be held to specific timeframes to process an authorization for adesignated representative. Health plan Workgroup members expressed support for a standardauthorization form. The Workgroup recommends that a standard form be developed for an insured todesignate an authorized representative and that such form be accepted by all health plans.Services that Require PreauthorizationWorkgroup members representing providers expressed concern that each health plan has adifferent set of services that require preauthorization, so that providers with patients covered underdifferent health plans hav

Oct 3, 2021