2006 New York Code - Standards For Certification.

 
    §  4912.  Standards  for  certification.  (a) The superintendent shall
  develop an application for certification. At a minimum, applicants shall
  provide:
    (1) a description of the qualifications of the clinical peer reviewers
  retained to conduct external appeals  of  final  adverse  determinations
  including  such  reviewers'  current  and  past  employment  history and
  practice affiliations;
    (2) a description of the procedures employed to ensure  that  clinical
  peer reviewers conducting external appeals are:
    (i) appropriately licensed, registered or certified;
    (ii)  trained  in  the  principles,  procedures  and  standards of the
  external appeal agent; and
    (iii) knowledgeable about the health care service which is the subject
  of the final adverse determination under appeal;
    (3) a description of the methods of recruiting and selecting impartial
  clinical peer reviewers and matching such reviewers to specific cases;
    (4) the number of clinical peer reviewers  retained  by  the  external
  appeal agent, and a description of the areas of expertise available from
  such  reviewers  and  the types of cases such reviewers are qualified to
  review;
    (5) a description of the policies and procedures employed  to  protect
  the  confidentiality  of  individual  medical  and  treatment records in
  accordance with applicable state and federal laws;
    (6) a description of the quality assurance program established by  the
  external  appeal  agent pursuant to paragraph three of subsection (b) of
  this section;
    (7)  the  names  of  all  corporations  and  organizations  owned   or
  controlled  by the external appeal agent, or which owns or controls such
  agent, and the nature and extent of any such ownership or control;
    (8)  the  names  and  biographies  of  all  directors,  officers,  and
  executives of the external appeal agent;
    (9)  an  experimental  and  investigational  treatment  review plan to
  conduct appeals pursuant  to  subparagraph  (B)  of  paragraph  four  of
  subsection  (b)  of  section four thousand nine hundred fourteen of this
  title; and
    (10) a description of the fees to be charged by  agents  for  external
  appeals.
    (b) The superintendent shall, at a minimum, require an external appeal
  agent to:
    (1)  appoint a medical director, who is a physician in possession of a
  current and valid non-restricted  license  to  practice  medicine.  Such
  director  shall  be responsible for the supervision and oversight of the
  external appeal process;
    (2) develop written policies and procedures governing all  aspects  of
  the appeal process, including, at a minimum:
    (i)  procedures  to  ensure that appeals are conducted within the time
  frames specified in section four thousand nine hundred fourteen of  this
  title, and any required notices are provided in a timely manner;
    (ii)  procedures  to  ensure  the selection of qualified and impartial
  clinical peer reviewers. Such reviewers shall be qualified to render and
  impartial determinations relating to the health care  service  which  is
  the subject of the final adverse determination under appeal;
    (iii)   procedures  to  ensure  the  confidentiality  of  medical  and
  treatment records and review materials; and
    (iv) procedures to ensure adherence to the requirements of this  title
  by   any   contractor,   subcontractor,  subvendor,  agent  or  employee
  affiliated by contract or otherwise with such external appeal agent;
    (3) establish a quality assurance program. Such program shall  include
  written descriptions, to be provided to all individuals involved in such
  program,  of  the organizational arrangements and ongoing procedures for
  the identification, evaluation, resolution and  follow-up  of  potential
  and actual problems in external appeals performed by the external appeal
  agent  and  to  ensure  the maintenance of program standards pursuant to
  this section;
    (4) establish a toll-free telephone service to receive information  on
  a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant
  to  this  title. Such system shall be capable of accepting, recording or
  providing instruction to incoming  telephone  calls  during  other  than
  normal business hours, and;
    (5) develop procedures to ensure that:
    (i)  appropriate  personnel  are  reasonably  accessible not less than
  forty hours per week during normal business  hours  to  discuss  patient
  care and to allow response to telephone requests, and
    (ii)  response to accepted or recorded messages shall be made not less
  than one business day after the date on which the call was received.
    (c)  No  entity  shall  be  qualified  to  submit  such  request   for
  application  if  it  owns  or  controls,  is  owned or controlled by, or
  exercises common control with, any of the following:
    (1) any national, state or local illness,  health  benefit  or  public
  advocacy group;
    (2)  any national, state or local society or association of hospitals,
  physicians, or other providers of health care services; or
    (3) any national, state or local association of health care plans.
    (d) A health care plan shall transmit, and an  external  appeal  agent
  shall  be  authorized  to  receive  and review, an insured's medical and
  treatment records in order to conduct an  external  appeal  pursuant  to
  this title.
    (e)  An  external  appeal  agent  shall  provide  ready  access to the
  superintendent to all  data,  records,  and  information  collected  and
  maintained concerning such agent's external appeal activities.
    (f) An external appeal agent shall agree to provide the superintendent
  such  data,  information,  and  reports as the superintendent determines
  necessary to evaluate the external appeal process  established  pursuant
  to this title.
    (g)  The  superintendent  shall  provide,  upon  the  request  of  any
  interested person, a copy of all non-proprietary information filed  with
  the  superintendent by the external appeal agent. The superintendent may
  charge a reasonable fee to the interested  person  for  reproducing  the
  requested information.