2006 New York Code - Required And Prohibited Practices.

 
    § 4905. Required and prohibited practices. (a) Each utilization review
  agent  shall  have written procedures for assuring that patient-specific
  information obtained during the process of utilization review will be:
    (1) kept confidential in accordance with applicable state and  federal
  laws; and
    (2)  shared  only  with  the  insured,  the  insured's  designee,  the
  insured's health care provider and those who are authorized  by  law  to
  receive such information.
    (b)  Summary  data shall not be considered confidential if it does not
  provide information to allow identification of individual patients.
    (c) Any health care professional who  makes  determinations  regarding
  the  medical  necessity  of  health  care  services during the course of
  utilization  review  shall  be  appropriately  licensed,  registered  or
  certified.
    (d)  A utilization review agent shall not, with respect to utilization
  review activities, permit or provide compensation or anything  of  value
  to its employees, agents, or contractors based on:
    (1)  either a percentage of the amount by which a claim is reduced for
  payment or the number of claims or the cost of services  for  which  the
  person has denied authorization or payment; or
    (2)  any  other  method  that  encourages  the rendering of an adverse
  determination.
    (e) If a health care service has been  specifically  preauthorized  or
  approved  for  an  insured  by a utilization review agent, a utilization
  review agent shall not pursuant to retrospective review revise or modify
  the specific standards, criteria or procedures used for the  utilization
  review  for procedures, treatment and services delivered to the insured,
  during the same course of treatment.
    (f) Utilization review shall not be conducted more frequently than  is
  reasonably  required  to  assess  whether the health care services under
  review are medically necessary.
    (g)   When   making   prospective,   concurrent   and    retrospective
  determinations,  utilization  review  agents  shall  collect  only  such
  information as is necessary to make such  determination  and  shall  not
  routinely require health care providers to numerically code diagnoses or
  procedures  to  be  considered  for  certification  or routinely request
  copies of medical records of all patients reviewed.  During  prospective
  or  concurrent  review, copies of medical records shall only be required
  when necessary to verify that the health care services subject  to  such
  review  are  medically  necessary.  In such cases, only the necessary or
  relevant sections of the medical record shall be required. A utilization
  review agent may request copies of partial or complete  medical  records
  retrospectively.  This  subsection shall not apply to health maintenance
  organizations licensed pursuant to article forty-three of  this  chapter
  or certified pursuant to article forty-four of the public health law.
    (h)  In  no  event  shall information be obtained from the health care
  providers for the use of the utilization review agent by  persons  other
  than   health   care  professionals,  medical  record  technologists  or
  administrative personnel who have received appropriate training.
    (i) The utilization  review  agent  shall  not  undertake  utilization
  review  at  the site of the provision of health care services unless the
  utilization review agent:
    (1) Identifies himself or herself by name and the name of his  or  her
  organization,  including  displaying  photographic  identification which
  includes the name of the utilization review agent and clearly identifies
  the individual as representative of the utilization review agent;
    (2) Whenever possible, schedules review at least one business  day  in
  advance with the appropriate health care provider;
    (3)  If  requested by a health care provider, assures that the on-site
  review staff register with the appropriate contact person, if available,
  prior to requesting any clinical  information  or  assistance  from  the
  health care provider; and
    (4)  Obtains consent from the insured or the insured's designee before
  interviewing the patient's family, or observing any health care  service
  being provided to the insured.
    (5)  This  subsection  shall  not  apply  to health care professionals
  engaged in providing care or case management or making on-site discharge
  decisions.
    (j) A utilization review agent shall not base an adverse determination
  on a refusal to consent to observing any health care service.
    (k) A utilization review agent shall not base an adverse determination
  on lack of reasonable access to a  health  care  provider's  medical  or
  treatment  records  unless  the  utilization  review  agent has provided
  reasonable  notice  to  the  insured,  the  insured's  designee  or  the
  insured's  health  care  provider,  in  which  case  the insured must be
  notified, and has complied with all provisions of subsection (i) of this
  section.
    (l) Neither the utilization review agent nor the entity for which  the
  agent  provides utilization review shall take any action with respect to
  a patient or a health care provider that is intended  to  penalize  such
  insured,  the  insured's designee, or the insured's health care provider
  for, or to discourage such  insured,  the  insured's  designee,  or  the
  insured's  health  care  provider  from  undertaking  an appeal, dispute
  resolution or judicial review of an adverse determination.
    (m) In no event shall an insured, an insured's designee, an  insured's
  health  care  provider,  any  other  health  care provider, or any other
  person or entity be required to inform or contact the utilization review
  agent prior to the provision  of  emergency  care,  including  emergency
  treatment or emergency admission.
    (n)  No contract or agreement between a utilization review agent and a
  health care provider shall contain any clause purporting to transfer  to
  the  health  care provider by indemnification or otherwise any liability
  relating to activities, actions or omissions of the  utilization  review
  agent as opposed to the health care provider.
    (o)  A  health  care professional providing health care services to an
  insured shall be prohibited from serving as the clinical  peer  reviewer
  for  such  insured  in  connection  with  the health care services being
  provided to the insured.