N.Y. Ins. Law § 4902

§ 4902. Utilization review program standards. (a) Each utilization\nreview agent shall adhere to utilization review program standards\nconsistent with the provisions of this title which shall, at a minimum,\ninclude:\n (1) Appointment of a medical director, who is a licensed physician;\nprovided, however, that the utilization review agent may appoint a\nclinical director when the utilization review performed is for a\ndiscrete category of health care service and provided further that the\nclinical director is a licensed health care professional who typically\nmanages the category of service. Responsibilities of the medical\ndirector, or, where appropriate, the clinical director, shall include,\nbut not be limited to, the supervision and oversight of the utilization\nreview process;\n (2) Development of written policies and procedures that govern all\naspects of the utilization review process and a requirement that a\nutilization review agent shall maintain and make available to insureds\nand health care providers a written description of such procedures\nincluding procedures to appeal an adverse determination together with a\ndescription, jointly promulgated by the superintendent and the\ncommissioner of health as required pursuant to subsection (e) of section\nfour thousand nine hundred fourteen of this article, of the external\nappeal process established pursuant to title two of this article and the\ntime frames for such appeals;\n (3) Utilization of written clinical review criteria developed pursuant\nto a utilization review plan;\n (4) Establishment of a process for rendering utilization review\ndeterminations which shall, at a minimum, include: written procedures to\nassure that utilization reviews and determinations are conducted within\nthe timeframes established herein; procedures to notify an insured, an\ninsured's designee and/or an insured's health care provider of adverse\ndeterminations; and procedures for appeal of adverse determinations\nincluding the establishment of an expedited appeals process for denials\nof continued inpatient care or where there is imminent or serious threat\nto the health of the insured;\n (5) Establishment of a written procedure to assure that the notice of\nan adverse determination includes:\n (i) the reasons for the determination including the clinical\nrationale, if any;\n (ii) instructions on how to initiate standard and expedited appeals\npursuant to section four thousand nine hundred four of this article and\nan external appeal pursuant to section four thousand nine hundred\nfourteen of this article; and\n (iii) notice of the availability, upon request of the insured or the\ninsured's designee, of the clinical review criteria relied upon to make\nsuch determination;\n (6) Establishment of a requirement that appropriate personnel of the\nutilization review agent are reasonably accessible by toll-free\ntelephone:\n (i) not less than forty hours per week during normal business hours to\ndiscuss patient care and allow response to telephone requests, and to\nensure that such utilization review agent has a telephone system capable\nof accepting, recording or providing instruction to incoming telephone\ncalls during other than normal business hours and to ensure response to\naccepted or recorded messages not less than one business day after the\ndate on which the call was received; or\n (ii) notwithstanding the provisions of subparagraph (i) of this\nparagraph, not less than forty hours per week during normal business\nhours, to discuss patient care and allow response to telephone requests,\nand to ensure that, in the case of a request submitted pursuant to\nsubsection (a) of section four thousand nine hundred three of this title\nor an expedited appeal filed pursuant to subsection (b) of section four\nthousand nine hundred four of this title, on a twenty-four hour a day,\nseven day a week basis;\n (7) Establishment of appropriate policies and procedures to ensure\nthat all applicable state and federal laws to protect the\nconfidentiality of individual medical records are followed;\n (8) Establishment of a requirement that emergency services rendered to\nan insured shall not be subject to prior authorization nor shall\nreimbursement for such services be denied on retrospective review;\nprovided, however, that such services are medically necessary to\nstabilize or treat an emergency condition.\n (9) When conducting utilization review for purposes of determining\nhealth care coverage for substance use disorder treatment, a utilization\nreview agent shall utilize evidence-based and peer reviewed clinical\nreview tools designated by the office of alcoholism and substance abuse\nservices that are appropriate to the age of the patient and consistent\nwith the treatment service levels within the office of alcoholism and\nsubstance abuse services system. All approved tools shall have inter\nrater reliability testing completed by December thirty-first, two\nthousand sixteen.\n (b) Each utilization review agent shall assure adherence to the\nrequirements stated in subsection (a) of this section by all\ncontractors, subcontractors, subvendors, agents and employees affiliated\nby contract or otherwise with such utilization review agent.\n