120.926 Private Insurers and Managed Care Organizations Pre–Authorization/Pre–Certification Protocols
The Medical Society of the State of New York (MSSNY) will seek legislation or regulation applying to all insurers which will:
Require insurance companies to provide clear instructions in a timely manner about the procedure for obtaining a prior authorization;
Require that for each plan or product, the insurer post on its website a complete list of services requiring pre–certification/pre–authorization;
Require that after a physician has telephoned a customer service representative (CSR) to determine whether a service requires pre–certification/pre–authorization, the insurer will send a written confirmation of the CSR’s verbal statement by fax or e-mail to the physician;
Prohibit the insurer from denying a claim solely for lack of an electronic pre–authorization/pre–certification request, if (a) the CSR has stated verbally that the service does not require pre–authorization/pre–certification but that statement was inaccurate, and (b) the physician, relying on the CSR’s verbal statement, failed to submit an electronic pre–authorization/pre–certification request; and
Ensure that when pre-authorization is not required, a physician can request from the insurance company a written predetermination about whether a particular procedure will be covered for a particular patient, and that predetermination shall be binding. (HOD 2016-260 & 261)
