UPDATE: Utilization Management Updates in Response to Executive Order Addressing Healthcare Staffing Shortages
9/7/2022
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Posted by Provider Relations
On September 27, 2021, Governor Kathy Hochul issued Executive Order No. 4 (“EO 4”) to address hospital staffing shortages. As a result, the Department of Financial Services issued Insurance Circular Letter No. 9 (2021): Hospital Staffing and Suspension of Utilization Review Requirements and Appeal Timeframes | Department of Financial Services (ny.gov) on October 7, 2021.
On August 28, 2022, Governor Hochul issued Executive Order No. 4.12 (“EO 4.12”), which terminated the suspension of utilization review and internal and external appeal timeframes for hospitals. Therefore, the provisions of EO 4 regarding the suspension of utilization review and the internal and external appeal timeframes for hospitals, ended as of August 28, 2022.
The suspension of utilization requirements for preauthorization included review for scheduled surgeries in hospital facilities, hospital admissions, hospital outpatient services, home health care services following a hospital admission, inpatient and outpatient rehabilitation services following a hospital admission, concurrent review for inpatient and outpatient hospital services, and retrospective review for inpatient and outpatient hospital services at in-network hospitals.
Additionally, in accordance with EO 4.12, the timeframes that had been communicated for hospitals to submit internal or external appeals are reset as of August 28, 2022. Therefore, hospitals have 45 days to submit an internal appeal or 60 days to submit an external appeal starting from August 28, 2022.
A copy of the New York State Department of Health notice posted on August 29, 2022 can be found here.
Please forward any questions regarding this guidance to URAgent@health.ny.gov or contact your local Provider Relations Specialist.