2006 New York Code - Utilization Review Determinations.

 
    §  4903.  Utilization  review  determinations.  (a) Utilization review
  shall be conducted by:
    (1) 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;
    (2) 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
    (3) A clinical peer reviewer where  the  review  involves  an  adverse
  determination.
    (b)  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 insured
  or  insured's  designee  and  the  insured's  health  care  provider  by
  telephone  and  in  writing within three business days of receipt of the
  necessary information.
    (c) A utilization review agent shall make  a  determination  involving
  continued  or  extended health care services, or additional services for
  an insured undergoing a course of continued treatment  prescribed  by  a
  health  care  provider  and  provide notice of such determination to the
  insured or the insured's designee, which may be satisfied by  notice  to
  the  insured's  health care provider, by telephone and in writing within
  one business day of receipt of the necessary  information.  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.
    (d) 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.
    (e) Notice of an adverse determination made by  a  utilization  review
  agent shall be in writing and must include:
    (1)   the   reasons  for  the  determination  including  the  clinical
  rationale, if any;
    (2) instructions on how to initiate  standard  appeals  and  expedited
  appeals  pursuant  to  section  four  thousand  nine hundred four and an
  external appeal pursuant to section four thousand nine hundred  fourteen
  of this article; and
    (3)  notice  of  the availability, upon request of the insured, or the
  insured'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.
    (f) In the event that a utilization review agent  renders  an  adverse
  determination  without  attempting  to  discuss  such  matter  with  the
  insured'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 insured'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 subsection (e) of this section. Nothing
  in this section shall preclude the insured  from  initiating  an  appeal
  from an adverse determination.
    (g)  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  four
  thousand nine hundred four of this title.