New York's Credentialing Deadlines and Provisional Participation

New York's managed care law does two things that matter to a clinician waiting on an insurer. It sets a 60-day deadline for the insurer to answer a completed application, and it turns that deadline into in-network participation for a defined group of clinicians: the newly licensed and the newly arrived who join a group whose members already participate. The rules sit in Insurance Law 4803 for insurers and in the parallel Public Health Law 4406-d for HMOs.

What does the 60-day rule say?

An insurer that offers a managed care product "shall complete review of the health care professional's application to participate in the in-network portion of the insurer's network and, within sixty days of receiving a health care professional's completed application to participate in the insurer's network, will notify the health care professional as to: (A) whether he or she is credentialed; or (B) whether additional time is necessary to make a determination because of a failure of a third party to provide necessary documentation" (Ins. Law 4803(a)(1)). When more time is needed because documents are missing, the insurer must "make every effort to obtain such information as soon as possible and shall make a final determination within twenty-one days of receiving the necessary documentation."

Public Health Law 4406-d(1)(a) imposes the same 60-day and 21-day rule on health care plans.

The same subsection requires insurers, "upon request," to "make available and disclose to health care professionals written application procedures and minimum qualification requirements," developed in consultation with appropriately qualified health care professionals. Ask for them before you apply and again after any denial.

Who gets provisional credentialing after 60 days?

Insurance Law 4803(a)(2) covers two kinds of clinicians who join "a group practice of health care professionals each of whom participates in the in-network portion of an insurer's network":

• a "newly-licensed health care professional"; or
• a health care professional "who has recently relocated to this state from another state and has not previously practiced in this state."

If that clinician's completed application "is neither approved nor declined within sixty days," the clinician "shall be deemed 'provisionally credentialed' and may participate in the in-network portion of an insurer's network." Participation "shall begin on the day following the sixtieth day of receipt of the completed application and shall last until the final credentialing determination is made."

Limits: "a provisionally credentialed physician may not be designated as an insured's primary care physician until such time as the physician has been fully credentialed." And it only applies if every member of the group participates in network, so a group with some non-participating members should check its roster before relying on it.

Does the group have to promise anything?

Provisional credentialing is available "only if the group practice ... notifies the insurer in writing" that, if the application is ultimately denied, the clinician or group:

• "shall refund any payments made by the insurer for in-network services provided by the provisionally credentialed health care professional that exceed any out-of-network benefits payable under the insured's contract"; and
• "shall not pursue reimbursement from the insured, except to collect the copayment or coinsurance that otherwise would have been payable" in network.

Send that letter with the application, not after day 60. The statute also says interest and penalties under the prompt pay law will not be assessed on claims denied during the provisional period, and that an insurer "shall not deny, after appeal, a claim for services provided by a provisionally credentialed health care professional solely on the ground that the claim was not timely filed."

Is there a separate path for hospital-employed physicians?

Yes. Under 4803(a)(3), a physician who is newly licensed, recently relocated to New York, or whose change in corporate relationship produced a new tax identification number after a prior participation contract, and "who becomes employed by a general hospital or diagnostic and treatment center licensed pursuant to article twenty-eight of the public health law, or a facility licensed under article sixteen, article thirty-one or article thirty-two of the mental hygiene law" that participates with the insurer, is deemed provisionally credentialed once the insurer receives the hospital's and physician's completed sections of the application and written notice that the physician has been granted hospital privileges. The insurer need not pay the facility for that physician's services until full credentialing; once credentialed, the facility is paid for services the physician provided during a defined window. If the application is denied, the insurer's liability is capped at out-of-network benefits and the facility may not bill the patient beyond normal cost sharing.

If an insurer terminates you, what applies?

Insurance Law 4803(b) requires a written explanation of the reasons for a proposed termination and "an opportunity for a review or hearing," except in cases of imminent harm to patient care, a determination of fraud, or a final disciplinary action that impairs the ability to practice. The notice must give at least 30 days to request a hearing or review. The hearing panel has three people appointed by the insurer, at least one "a clinical peer in the same discipline and the same or similar specialty," and the decision is in writing. A termination decision is effective not less than 30 days after you receive it, and "In no event shall termination be effective earlier than sixty days from the receipt of the notice of termination." See without-cause terminations.

Where do these rules stop?

• They are timeliness rules, not admission rules. An insurer can still decline you. The law makes it answer within 60 days and, for eligible clinicians, pay you in the meantime.
• Self-funded employer plans are generally outside state insurance law under ERISA.
• Medicare Advantage follows federal rules; state laws on provider inclusion are superseded there.
• Medicaid managed care adds a state enrollment step. UnitedHealthcare's regulatory addendum (revised 9/2026), restating New York's Medicaid contract, says a provider not on the state's active or pending fee-for-service enrollment file "will be denied" credentialing.

How should you use the 60-day clock?

1. Submit a truly complete application and keep dated proof of receipt.
2. If you qualify for provisional credentialing, have the group send the refund and hold-harmless letter at the same time.
3. On day 61, if there is no decision and no request for third-party documents, write to the insurer noting that provisional participation began the day after day 60 under 4803(a)(2) or PHL 4406-d.
4. If the insurer cites missing third-party documents, track the 21-day final decision clock from when they arrive.

Our provisional credentialing laws post compares New York with other states.

Our role in a New York file

We research, prepare and organize; we are not a law firm and do not represent clinicians. A Network Rejection Review ($249, credited toward a dispute) checks whether your application was complete, whether you qualify for provisional credentialing and which clocks are running. A Payer Network Dispute ($799 per payer) prepares the day-61 letter, the group's written undertaking, any reconsideration request and the supporting file. You and your group sign and send them; we track the dates. A credentialing approval or contract carries a flat $1,500 win fee. Questions about termination hearings or your legal rights go to a New York healthcare attorney. See our New York page for more.