120.965 Medically Necessary Procedures and Pre-certification and Pre-authorization Protocols:
MSSNY will:
- Seek the enactment of legislation, regulation or other appropriate means to eliminate the need to obtain pre-authorization for certain procedures and tests that are clearly indicated, including for urgent and emergency care, based upon a patient’s particular health condition as defined by relevant physician specialty society guidelines;
- Take appropriate steps to assure that health plans obtain meaningful clinical input from New York physicians representative of all specialties, through practicing physician liaison committees, in determining which services should require pre-authorization or pre-certification;
- Take appropriate steps to assure that health plans promptly respond to required pre-authorization requests for tests within 24 hours, including the imposition of meaningful penalties on health plans, and requiring payment for the requested services when such authorization is not received in a timely manner;
- Advocate for a statutory definition of “medical necessity” which gives appropriate discretion to a physician requesting the health care service or treatment for the patient, provided the care is consistent with generally accepted standards of medical practice, and clinically appropriate to the patient’s condition. (HOD 2008-50; Reaffirmed HOD 2016-262; Reaffirmed Council 11/27/24)
