Bill > S04833

This bill amends New York insurance and public health laws to protect healthcare providers by preventing health insurance plans from arbitrarily changing medical necessity determinations during claims reviews. Specifically, the bill prohibits health plans from reversing or altering medical necessity determinations (including decisions about the site of service or level of care) that were originally made by a utilization review agent or external appeals agent. The bill also defines a new type of "adverse determination" that includes downcoding a claim, which means reducing the billing code to a lower-level service than what was originally submitted by the healthcare provider. This means that if a healthcare provider submits a claim with a specific service level, the insurance company cannot unilaterally change the coding in a way that would reduce reimbursement, unless they have a legitimate reason related to fraud, waste, or abuse detection. The legislation aims to provide more protection for healthcare providers against arbitrary claim adjustments and ensure that medical necessity determinations are respected in the claims review process.

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https://www.nysenate.gov/legislation/bills/2025/S4833