Network Adequacy Submission Instructions

General Information

The following provides instructions about the submission of provider networks to the Department of Financial Services (“DFS”) through the System for Electronic Rate and Form Filing (“SERFF”) and the Provider Network Data System (“PNDS”). The following also provides information about network adequacy requirements and standards for medical, stand‐alone dental and stand‐alone vision insurers. Insurers, corporations organized pursuant to article 43 of the Insurance Law, municipal cooperative health benefit plans certified pursuant to article 47 of the Insurance Law, and student health plans (collectively “insurers”) established or maintained pursuant to section 1124 of the Insurance Law need to submit their networks for review by DFS unless the network has been determined adequate by the Department of Health (“DOH”) pursuant to standards in the Public Health Law.

Beginning in October 2016, DFS will transition from a manual review that is conducted annually using SERFF to an electronic review that is conducted quarterly using the PNDS. All networks with the exception of those networks that are the same as those previously approved by DOH or the New York State of Health (“NYSOH”) are expected to be submitted using the new PNDS. Furthermore, beginning at this time, review will be done quarterly and quarterly submissions are required even if there are no changes to the network. Please contact [email protected] with any questions.

PNDS Submission Requirements

The primary purpose of the PNDS is to collect the data needed to evaluate provider networks, including physicians, hospitals, labs, home health agencies, durable medical equipment providers, etc. for all health insurers in New York State.

DFS network adequacy review will be conducted quarterly for all medical, stand‐alone dental and stand‐ alone vision networks not reviewed by DOH or the NYSOH. Insurers will submit provider network information electronically to the PNDS on a quarterly basis (at a minimum). This data will be used for a network adequacy review by DFS and will also be made available through a public facing provider lookup tool.

In addition to the quarterly submissions for network adequacy analysis, insurers should update their network submission in PNDS within 15 days of any change to the network. If no network changes occur, then a quarterly submission in accordance with the data submission schedule will be sufficient.

However, major changes to the network, such as the loss of a hospital system, may require a network adequacy submission for analysis in between quarters. The data reported in the submission must comply with the Provider Network Data Dictionary (“Data Dictionary”), available on the DOH PNDS website.

1. Accessing PNDS

   Connection to the PNDS is through a secure connection via a web portal, available at https://pnds.health.ny.gov. Each plan should have self‐designated at least 2 Coordinators. Coordinators can log into PNDS to create additional accounts for Plan Submitters. A Plan Submitter is responsible for the submission and maintenance of data into the PNDS.

2. Data Submission Schedule

   Insurers should submit their networks for review each quarter. Quarters will end March 31, June 30, September 30, and December 31 for all submissions. These submissions will provide a snapshot of the

   network that will be used for analysis. The snapshot of the data will be the business week that includes the last day of the month. For example, if the 31st is a Wednesday, the week would be the 29th through the 2nd. Test submissions may be submitted at any time. Other submissions, including corrections and service area expansions, are submitted on an as needed basis.

SERFF Submission Requirements

While networks will be submitted to PNDS, submission of other documents in SERFF will still be required in certain instances. These filings should be submitted as Form Only filings that are Filed for Reference. The filing type of insurance (TOI) is H21 Health – Other and the filing type is Network Adequacy. It is not necessary to submit these quarterly. These submissions should instead be submitted annually and include the documents described below:

For a network that was previously approved by DOH or NYSOH:

1. A Network Adequacy Attestation should be submitted in SERFF in PDF format.

When submitting a non‐previously approved network (either in whole or in part) in PNDS for review by DFS the following supporting documents should be submitted in SERFF:

1. The provider selection criteria in PDF format;
2. The quality assurance procedures in PDF format;
3. A sample provider agreement; and
4. Any additional attestations or affirmations as applicable.

Provider Standards

In general, the network should have the following minimum numbers of providers for each provider type per county in order be considered adequate. Refer to the Data Dictionary for more precise submission requirements.

Medical Providers

Stand-Alone Dental Providers

Stand-Alone Vision Providers