2019 New York Laws
ISC - Insurance
Article 49 - Utilization Review and External Appeal
Title 1 - Registration of Agents and Review Process
4901 - Reporting Requirements for Utilization Review Agents.

§  4901.  Reporting  requirements  for  utilization review agents. (a)
Every  utilization  review  agent  shall  biennially   report   to   the
superintendent  of  financial  services,  in  a statement subscribed and
affirmed as  true  under  the  penalties  of  perjury,  the  information
required pursuant to subsection (b) of this section.
  (b) Such report shall contain a description of the following:
  (1) The utilization review plan;
  (2) Those circumstances, if any, under which utilization review may be
delegated  to  a  utilization  review  program  conducted  by a facility
licensed pursuant to article twenty-eight of the public  health  law  or
pursuant to article thirty-one of the mental hygiene law;
  (3)  The  provisions by which an insured, the insured's designee, or a
health care provider may seek reconsideration of or appeal from  adverse
determinations  by  the utilization review agent, in accordance with the
provisions of this title, including provisions to ensure a timely appeal
and that an insured, the insured's designee, and,  in  the  case  of  an
adverse  determination  involving  a  retrospective  determination,  the
insured's health care provider is informed  of  their  right  to  appeal
adverse determinations;
  (4) Procedures by which a decision on a request for utilization review
for  services  requiring  preauthorization  shall comply with timeframes
established pursuant to this title;
  (5) A description of an emergency care policy, which shall include the
procedures under which an emergency admission shall be made or emergency
treatment shall be given;
  (6) A description of the personnel  utilized  to  conduct  utilization
review   including  a  description  of  the  circumstances  under  which
utilization review may be conducted by:
  (i) administrative personnel;
  (ii) health care professionals who are not  clinical  peer  reviewers;
and
  (iii) clinical peer reviewers;
  (7)   A   description  of  the  mechanisms  employed  to  assure  that
administrative personnel are trained in the principles and procedures of
intake screening and data collection and are appropriately monitored  by
a  licensed  health care professional while performing an administrative
review;
  (8) A description of the mechanisms employed  to  assure  that  health
care professionals conducting utilization review are:
  (i) appropriately licensed, registered or certified; and
  (ii)  trained  in  the  principles,  procedures  and standards of such
utilization review agent.
  (9) A description of the mechanisms employed to  assure  that  only  a
clinical peer reviewer shall render an adverse determination;
  (10)   Provisions   to   ensure  that  appropriate  personnel  of  the
utilization  review  agent  are  reasonably  accessible   by   toll-free
telephone:
  (i)  not  less than forty hours per week during normal business hours,
to discuss patient care and allow response to telephone requests, and to
ensure that such utilization review agent has a telephone system capable
of accepting, recording or providing instruction to  incoming  telephone
calls  during other than normal business hours and to ensure response to
accepted or recorded messages not less than one business day  after  the
date on which the call was received; or
  (ii)  notwithstanding  the  provisions  of  subparagraph  (i)  of this
paragraph, not less than forty hours per  week  during  normal  business
hours, to discuss patient care and allow response to telephone requests,
and  to  ensure  that,  in  the  case of a request submitted pursuant to

subsection (a) of section four thousand nine hundred three of this title
or an expedited appeal filed pursuant to subsection (b) of section  four
thousand  nine  hundred four of this title, on a twenty-four hour a day,
seven day a week basis;
  (11)  The  policies and procedures to ensure that all applicable state
and federal laws to protect the confidentiality  of  individual  medical
and treatment records are followed;
  (12)  A  copy  of  the  materials  to  be  disclosed  to an insured or
prospective insured pursuant to  sections  three  thousand  two  hundred
seventeen-a  or four thousand three hundred twenty-four of this chapter,
whichever is applicable, and this title;
  (13) A description of  the  mechanisms  employed  by  the  utilization
review  agent  to  assure that all subcontractors, subvendors, agents or
employees affiliated by contract  or  otherwise  with  such  utilization
review  agent  will  adhere  to  the  standards and requirements of this
title; and
  (c) The clinical review criteria and standards  contained  within  the
utilization  review  plan shall not be subject to disclosure pursuant to
the provisions of article six of the public officers law.