2013 New York Consolidated Laws
PBH - Public Health
Article 49 - UTILIZATION REVIEW AND EXTERNAL APPEAL
Title 1 - (4900 - 4908) CERTIFICATION OF AGENTS AND UTILIZATION REVIEW PROCESS
4903 - Utilization review determinations.

 
    § 4903. Utilization review determinations. 1. Utilization review shall
  be conducted by:
    (a)  Administrative personnel trained in the principles and procedures
  of  intake  screening  and  data  collection,  provided,  however,  that
  administrative  personnel  shall  only  perform  intake  screening, data
  collection and non-clinical review functions and shall be supervised  by
  a licensed health care professional;
    (b)  A  health  care  professional who is appropriately trained in the
  principles, procedures and standards of such utilization  review  agent;
  provided, however, that a health care professional who is not a clinical
  peer reviewer may not render an adverse determination; and
    (c)  A  clinical  peer  reviewer  where the review involves an adverse
  determination.
    * 2. A utilization  review  agent  shall  make  a  utilization  review
  determination    involving    health   care   services   which   require
  pre-authorization and provide notice of a determination to the  enrollee
  or  enrollee's  designee  and  the  enrollee's  health  care provider by
  telephone and in writing within three business days of  receipt  of  the
  necessary information.
    * NB Effective until July 1, 2014
    * 2.  A  utilization  review  agent  shall  make  a utilization review
  determination   involving   health   care   services    which    require
  pre-authorization  and provide notice of a determination to the enrollee
  or enrollee's designee  and  the  enrollee's  health  care  provider  by
  telephone  and  in  writing within three business days of receipt of the
  necessary  information.  To  the  extent   practicable,   such   written
  notification to the enrollee's health care provider shall be transmitted
  electronically, in a manner and in a form agreed upon by the parties.
    * NB Effective July 1, 2014
    3.  A  utilization  review  agent shall make a determination involving
  continued or extended health care services, additional services  for  an
  enrollee  undergoing  a  course  of  continued treatment prescribed by a
  health  care  provider,  or  home  health  care  services  following  an
  inpatient   hospital   admission,  and  shall  provide  notice  of  such
  determination to the enrollee or the enrollee's designee, which  may  be
  satisfied by notice to the enrollee's health care provider, by telephone
  and  in  writing  within  one  business  day of receipt of the necessary
  information except, with respect to home health care services  following
  an  inpatient hospital admission, within seventy-two hours of receipt of
  the necessary information when the day subsequent to the  request  falls
  on  a weekend or holiday. Notification of continued or extended services
  shall include the number of extended services approved, the new total of
  approved services, the date of onset of services  and  the  next  review
  date.  Provided  that  a  request  for home health care services and all
  necessary information is submitted to the utilization review agent prior
  to discharge from an  inpatient  hospital  admission  pursuant  to  this
  subdivision,  a utilization review agent shall not deny, on the basis of
  medical necessity or lack of  prior  authorization,  coverage  for  home
  health  care  services  while  a determination by the utilization review
  agent is pending.
    4.  A  utilization  review  agent  shall  make  a  utilization  review
  determination  involving  health care services which have been delivered
  within thirty days of receipt of the necessary information.
    5. Notice of an adverse determination made  by  a  utilization  review
  agent shall be in writing and must include:
    (a)   the   reasons  for  the  determination  including  the  clinical
  rationale, if any;

    (b) instructions on how to initiate  standard  and  expedited  appeals
  pursuant  to  section  forty-nine  hundred  four  and an external appeal
  pursuant to section forty-nine hundred fourteen of this article; and
    (c)  notice  of the availability, upon request of the enrollee, or the
  enrollee's designee, of the clinical review criteria relied upon to make
  such determination.  Such  notice  shall  also  specify  what,  if  any,
  additional  necessary  information  must be provided to, or obtained by,
  the utilization review agent in  order  to  render  a  decision  on  the
  appeal.
    6.  In  the  event  that a utilization review agent renders an adverse
  determination  without  attempting  to  discuss  such  matter  with  the
  enrollee's  health care provider who specifically recommended the health
  care service, procedure or treatment  under  review,  such  health  care
  provider  shall have the opportunity to request a reconsideration of the
  adverse determination. Except in cases of  retrospective  reviews,  such
  reconsideration  shall  occur  within one business day of receipt of the
  request and shall be conducted by the enrollee's  health  care  provider
  and  the  clinical  peer  reviewer making the initial determination or a
  designated clinical peer reviewer if the original clinical peer reviewer
  cannot be available. In the event  that  the  adverse  determination  is
  upheld after reconsideration, the utilization review agent shall provide
  notice as required pursuant to subdivision five of this section. Nothing
  in  this  section  shall preclude the enrollee from initiating an appeal
  from an adverse determination.
    7. Failure by the utilization review agent  to  make  a  determination
  within the time periods prescribed in this section shall be deemed to be
  an  adverse  determination  subject  to appeal pursuant to section forty
  nine hundred four of this title.