Bill > A08172

This bill establishes new requirements for how insurance companies must process and pay hospital claims in New York, creating a structured process for claim payment and subsequent medical necessity reviews. Specifically, insurers must pay hospital claims at the contracted rate within specified timeframes, regardless of their internal policies, and cannot delay payment for reasons like preauthorization or documentation requirements. After payment, insurers can request specific clinical documentation from hospitals within 90 days and submit it to a joint committee composed of equal representatives from the hospital and insurance company for a post-payment review. If there are questions about medical necessity, the joint committee will review the documentation, and if they cannot reach an agreement, they will forward the case to an independent third-party review agent whose determination will be binding. If the services are found not to be medically necessary, the hospital must refund the payment, and cannot bill the patient except for standard copayments or deductibles. The bill also includes provisions to limit the number of claims that can be reviewed and ensures that medical necessity definitions cannot simply reference an insurer's internal policies. The new regulations will take effect on January 1, 2026, and are designed to streamline and standardize the claims payment process between hospitals and insurers.

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https://www.nysenate.gov/legislation/bills/2025/A8172