S.3402/A.6898 – UR Response

This legislation, S.3402/A.6898, would require that a non-timely plan utilization review (UR) response be deemed “approved.”  The New York Health Plan Association (HPA) opposes this legislation because it undermines the quality of care for patients and does not solve the concerns articulated by the bill’s proponents.

As the sponsor’s memo notes, under current law, failure by the utilization review agent to make a determination within the statutory time period shall be deemed to be an adverse determination.  However, this does not absolve the UR entity of its obligation to inform the patient and provider.  In the event of an adverse determination, the utilization review agent is required to provide, in writing, the reasons for the determination including the clinical rationale, instructions to pursue an appeal, and notice of the availability of the clinical review criteria.  Further, for specific services, such as behavioral health and substance use disorders, there are statutory timeframes for UR agents to provide either a telephonic or written response for a request for service.

While there are statutory timeframes on health plans to respond, there are not comparable requirements on providers to submit all necessary information in a timely manner for a health plan to make a determination.  Such delays on the part of the provider can contribute to the UR agent not responding within the statutory timeframe.  By changing denials to approval for late utilization review responses, even in cases where health plans are waiting for information from the provider, S.3402/A.6898 will make it more difficult for health plans to protect patients and prevent unnecessary, inappropriate, and potentially harmful care.  Further, mandating an entirely new standard will add unnecessary administrative costs without providing any meaningful benefit to patients.

For these reasons, we urge you to reject S.3402/A.6898.