New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
ONE COMMERCE PLAZA
ALBANY, NEW YORK 12257

David A. Paterson
Governor

Eric R. Dinallo
Superintendent

OGC Op. No. 08-05-16

The Office of General Counsel issued the following opinion on May 30, 2008, representing the position of the New York Insurance Department.

Re: Utilization Review of Chiropractic Services

Questions Presented

1. May a managed care plan, health maintenance organization (HMO) or insurer deny a claim for a covered service after a predetermined number of visits to a doctor of chiropractic, or impose pre-authorization requirements, if the managed care plan, HMO or insurer would not otherwise deny the same claim, or impose pre-authorization requirements, where the service was rendered by a practitioner other than a doctor of chiropractic?

2. If the answer to the previous question is "no," may a third party administrator, utilization review agent, independent practice association (IPA) or other contract entity acting as agent for the managed care plan, HMO or insurer issue an adverse determination to a doctor of chiropractic, whereby a denial is made or prior approval is required after a certain number of visits for the doctor of chiropractic when, under similar circumstances, a denial would not be made or pre-approval would not otherwise be required for another health care provider rendering the same or similar services?

Conclusions

1. No. A managed care plan, HMO or insurer may not deny a claim for a covered service after a predetermined number of visits to a doctor of chiropractic, or impose pre-authorization requirements, if the managed care plan, HMO or insurer would not deny the same claim, or impose pre-authorization requirements where the service was rendered by a practitioner other than a doctor of chiropractic.

2. No. A third party administrator, utilization review agent, IPA or other contract entity acting as agent for the managed care plan, HMO or insurer may not issue an adverse determination to a doctor of chiropractic, whereby a denial is made or prior approval is required after a certain number of visits for the doctor of chiropractic when, under similar circumstances, a denial would not be made or pre-approval would not otherwise be required for another health care provider rendering the same or similar services.

Facts

The inquiry is of a general nature, without reference to particular facts.

Analysis

Chapter 426 of the Laws of 1997, codified at Insurance Law §§ 3216(i)(21), 3221(k)(11), and 4303(y) (Chiropractic Insurance Equality Law), is germane to the first query. Those statutes provide that all managed care and indemnity insurance policies offered for sale in New York that provide coverage for the diagnosis and treatment of conditions, complaints, ailments, disorders or injuries by any health care professional that may be diagnosed and treated by a doctor of chiropractic, must provide access to, and equivalent coverage for, the diagnosis and treatment of those conditions, complaints, ailments, disorders or injuries by a duly licensed doctor of chiropractic, within the lawful scope of chiropractic practice. Thus, such policies must provide coverage and utilization review for chiropractic care that is equivalent to the coverage provided under the terms of the particular insurance policy for the services of any other health care professional diagnosing and treating any covered condition, injury, ailment or disorder that may lawfully be treated by a chiropractor.

The Chiropractic Insurance Equality Law provides that such insurance policies may subject chiropractic to reasonable deductible, co-payment and coinsurance amounts, reasonable fee and benefit limits, and reasonable utilization review, provided that any such amounts, limits or reviews do not operate to direct treatment in a manner discriminative against chiropractic care. The same law further provides that any such amounts, limits or reviews individually and collectively are no more restrictive for chiropractic care than what are applicable under the same policy to the care provided by other health professionals in treating the same or similar conditions, ailments, injuries or disorders regardless of the terminology used by the various professions. The law assures that chiropractic patients are given the freedom to select treatment by a chiropractor or any other health professional on an equivalent basis under the terms of their health plan or policy.

As to the second question, if an insurer or HMO is subject to Chapter 426 of the Laws of 1997, the insurer or HMO is responsible for assuring that any agent or contractor acting on its behalf, including third party administrators, utilization review agents and IPAs, complies with the requirements of the law. These responsibilities, include, but are not limited to, equitable utilization review and nondiscrimination. (Insurance Law §§ 3216(i)(21), 3221(k)(11), and 4303(y), as added by Chapter 426 of the Laws of 1997.) To deny a claim or impose utilization review requirements for services performed by a doctor of chiropractic, when such a claim would not otherwise be denied or subject to utilization review when the same services are rendered by a provider other than a doctor of chiropractic, is prohibited by law.

The Consumer Services Bureau may also be accessed online at www.ins.state.ny.us.

For further information, you may contact Assistant Chief Thomas C. Zyra at the Albany office or Assistant Deputy Superintendent & Counsel Paul A. Zuckerman at the New York City office.