265.000 REIMBURSEMENT

265.969           Proper Insurance Claim Protocol: SUNSET HOD 2013

265.968           Pre-Authorization Denials: SUNSET HOD 2014

265.967           Recognition of Modifier 25: SUNSET HOD 2014

265.966           Circumvention of the Prompt Payment Law in New York State: MSSNY will seek amendment to the present Prompt Payment legislation to impose penalties on those carriers that have been determined to be circumventing the Prompt Payment law by “forcing claims to payment” to meet the prescribed deadlines and then demanding refunds well after the

265.965           Physician Appeal’s Mechanisms for Down Coded or Denied Claims: MSSNY will seek legislation and/or regulation to ensure that physicians have an appropriate appeals mechanism which third party payors should make available to physicians when claims have been denied or “down coded” by such payors.  Such legislation and/or regulation should require (a) all payors to

265.964           Review of Pre-Authorizations by a Licensed Physician: MSSNY will seek legislation to require that all pre-authorizations for procedures be reviewed by a New York State licensed practicing physician who is board certified or board eligible in the same specialty as the requesting physician prior to any denial of pre-authorization.  (HOD 2000-67; Reaffirmed HOD 2014;

265.963           All Products Clause in Insurance Participating Provider Contracts: MSSNY will seek legislation to ban “all products” clauses in health care plan participating provider contracts, and to bar health care plans from requiring participation in any other products as a requisite for participation in Child Health Plus or Family Health Plus.  (HOD 2000-68; Reaffirmed HOD

265.962           Enhancements to the Prompt Payment Law MSSNY will seek enhancements to the current Prompt Payment Law stipulating that when additional information has been requested and received from a physician and/or patient, that the health care plan requesting the information be required to process and pay that claim within a specified (reasonable) period of time,

265.961           Accountability of Management  Service Organizations: MSSNY will seek legislation which would (a) require that management service organizations that contract with health insurance entities to review, process and pay physician-submitted claims, grant authorizations and pre-certifications where appropriate, apply internal policy payment parameters frequently without physician input, be held accountable to the same State imposed standards,

265.960           Reimbursement of Accutane: SUNSET HOD 2024