Disclaimer: Law, rules and regulations, not Guidelines, specify the requirements for practice and violating them constitutes professional misconduct. Not adhering to this Guideline may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations.
Alert 18: Insurance Billing
New York State Education Law does not address issues of insurance coverage, benefits, or reimbursement. Education Law addresses the qualifications for a professional license, professional scopes of practice, and professional conduct. State Insurance Law sets forth the requirements for traditional indemnity plans, and the Insurance and Public Health Laws set forth the requirements for managed care organizations. Articles 32 and 43 of the Insurance Law define health insurance policies and mandate certain benefits and services, although not physical therapy by name. Article 48 of the Insurance Law specifies what must be included in managed care insurance contracts; Article 49 authorizes independent review and appeals for certain decisions. Article 44 and Article 49 of the Public Health Law address the same subjects, providing the Department of Health authority to oversee and regulate managed care organizations.
New York State laws can be found at
public.leginfo.state.ny.us/lawssrch.cgi?NVLWO:.
The web site for the Department of Health is
www.health.state.ny.us.
The functions of the former State Insurance Department have been moved to the Department of Financial Services, whose web site address is
www.dfs.ny.gov/insurance/dfs_insurance.htm.
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Citations of Pertinent Law, Rules or Regulations:
Insurance Law Article 32 – insurance contracts
Insurance Law Article 43 – non-profit medical and dental indemnity or health and hospital services corporations
Insurance Law Article 48 – managed care health insurance contracts
Insurance Law Article 49 – utilization review and external appeal
Public Health Law, Article 44 – health maintenance organizations
Public Health Law, Article 49 – utilization review and external appeal