§ 4406-d. Health care professional applications and terminations. 1.\n(a) A health care plan shall, upon request, make available and disclose\nto health care professionals written application procedures and minimum\nqualification requirements which a health care professional must meet in\norder to be considered by the health care plan. The plan shall consult\nwith appropriately qualified health care professionals in developing its\nqualification requirements. A health care plan shall complete review of\nthe health care professional's application to participate in the\nin-network portion of the health care plan's network and shall, within\nsixty days of receiving a health care professional's completed\napplication to participate in the health care plan's network, notify the\nhealth care professional as to: (i) whether he or she is credentialed;\nor (ii) whether additional time is necessary to make a determination\nbecause of a failure of a third party to provide necessary\ndocumentation. In such instances where additional time is necessary\nbecause of a lack of necessary documentation, a health plan shall make\nevery effort to obtain such information as soon as possible and shall\nmake a final determination within twenty-one days of receiving the\nnecessary documentation.\n (b) If the completed application of a newly-licensed health care\nprofessional or a health care professional who has recently relocated to\nthis state from another state and has not previously practiced in this\nstate, who joins a group practice of health care professionals each of\nwhom participates in the in-network portion of a health care plan's\nnetwork, is neither approved nor declined within sixty days of\nsubmission of a completed application pursuant to paragraph (a) of this\nsubdivision, the health care professional shall be deemed "provisionally\ncredentialed" and may participate in the in-network portion of the\nhealth care plan's network; provided, however, that a provisionally\ncredentialed physician may not be designated as an enrollee's primary\ncare physician until such time as the physician has been fully\ncredentialed. The network participation for a provisionally credentialed\nhealth care professional shall begin on the day following the sixtieth\nday of receipt of the completed application and shall last until the\nfinal credentialing determination is made by the health care plan. A\nhealth care professional shall only be eligible for provisional\ncredentialing if the group practice of health care professionals\nnotifies the health care plan in writing that, should the application\nultimately be denied, the health care professional or the group\npractice: (i) shall refund any payments made by the health care plan for\nin-network services provided by the provisionally credentialed health\ncare professional that exceed any out-of-network benefits payable under\nthe enrollee's contract with the health care plan; and (ii) shall not\npursue reimbursement from the enrollee, except to collect the copayment\nthat otherwise would have been payable had the enrollee received\nservices from a health care professional participating in the in-network\nportion of a health care plan's network. Interest and penalties pursuant\nto section three thousand two hundred twenty-four-a of the insurance law\nshall not be assessed based on the denial of a claim submitted during\nthe period when the health care professional was provisionally\ncredentialed; provided, however, that nothing herein shall prevent a\nhealth care plan from paying a claim from a health care professional who\nis provisionally credentialed upon submission of such claim. A health\ncare plan shall not deny, after appeal, a claim for services provided by\na provisionally credentialed health care professional solely on the\nground that the claim was not timely filed.\n (c) A newly-licensed physician, a physician who has recently relocated\nto this state from another state and has not previous
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