N.Y. Ins. Law § 4903

§ 4903. Utilization review determinations. (a) Utilization review\nshall be conducted by:\n (1) Administrative personnel trained in the principles and procedures\nof intake screening and data collection, provided however, that\nadministrative personnel shall only perform intake screening, data\ncollection and non-clinical review functions and shall be supervised by\na licensed health care professional;\n (2) A health care professional who is appropriately trained in the\nprinciples, procedures and standards of such utilization review agent;\nprovided, however, that a health care professional who is not a clinical\npeer reviewer may not render an adverse determination; and\n (3) A clinical peer reviewer where the review involves an adverse\ndetermination.\n * (b) A utilization review agent shall make a utilization review\ndetermination involving health care services which require\npre-authorization and provide notice of a determination to the insured\nor insured's designee and the insured's health care provider by\ntelephone and in writing within three business days of receipt of the\nnecessary information. To the extent practicable, such written\nnotification to the enrollee's health care provider shall be transmitted\nelectronically, in a manner and in a form agreed upon by the parties.\n * NB Effective until March 31, 2015\n * (b) A utilization review agent shall make a utilization review\ndetermination involving health care services which require\npre-authorization and provide notice of a determination to the insured\nor insured's designee and the insured's health care provider by\ntelephone and in writing within three business days of receipt of the\nnecessary information. To the extent practicable, such written\nnotification to the enrollee's health care provider shall be transmitted\nelectronically, in a manner and in a form agreed upon by the parties.\nThe notification shall identify: (1) whether the services are considered\nin-network or out-of-network; (2) whether the insured will be held\nharmless for the services and not be responsible for any payment, other\nthan any applicable co-payment, co-insurance or deductible; (3) as\napplicable, the dollar amount the health care plan will pay if the\nservice is out-of-network; and (4) as applicable, information explaining\nhow an insured may determine the anticipated out-of-pocket cost for\nout-of-network health care services in a geographical area or zip code\nbased upon the difference between what the health care plan will\nreimburse for out-of-network health care services and the usual and\ncustomary cost for out-of-network health care services.\n * NB Effective March 31, 2015\n * (c) A utilization review agent shall make a determination involving\ncontinued or extended health care services, additional services for an\ninsured undergoing a course of continued treatment prescribed by a\nhealth care provider, or home health care services following an\ninpatient hospital admission, and shall provide notice of such\ndetermination to the insured or the insured's designee, which may be\nsatisfied by notice to the insured's health care provider, by telephone\nand in writing within one business day of receipt of the necessary\ninformation except, with respect to home health care services following\nan inpatient hospital admission, within seventy-two hours of receipt of\nthe necessary information when the day subsequent to the request falls\non a weekend or holiday. Notification of continued or extended services\nshall include the number of extended services approved, the new total of\napproved services, the date of onset of services and the next review\ndate. Provided that a request for home health care services and all\nnecessary information is submitted to the utilization review agent prior\nto discharge from an inpatient hospital admission pursuant to this\nsubsection, a utilization review agent shall not deny, on the basis of\nmedical necessity or lack of prior authorization, coverage for home\nhealth care services while a determination by the utilization review\nagent is pending.\n * NB Effective until April 1, 2015\n * (c) (1) A utilization review agent shall make a determination\ninvolving continued or extended health care services, additional\nservices for an insured undergoing a course of continued treatment\nprescribed by a health care provider, or requests for inpatient\nsubstance use disorder treatment, or home health care services following\nan inpatient hospital admission, and shall provide notice of such\ndetermination to the insured or the insured's designee, which may be\nsatisfied by notice to the insured's health care provider, by telephone\nand in writing within one business day of receipt of the necessary\ninformation except, with respect to home health care services following\nan inpatient hospital admission, within seventy-two hours of receipt of\nthe necessary information when the day subsequent to the request falls\non a weekend or holiday and except, with respect to inpatient substance\nuse disorder treatment, within twenty-four hours of receipt of the\nrequest for services when the request is submitted at least twenty-four\nhours prior to discharge from an inpatient admission. Notification of\ncontinued or extended services shall include the number of extended\nservices approved, the new total of approved services, the date of onset\nof services and the next review date.\n (2) Provided that a request for home health care services and all\nnecessary information is submitted to the utilization review agent prior\nto discharge from an inpatient hospital admission pursuant to this\nsubsection, a utilization review agent shall not deny, on the basis of\nmedical necessity or lack of prior authorization, coverage for home\nhealth care services while a determination by the utilization review\nagent is pending.\n (3) Provided that a request for inpatient treatment for substance use\ndisorder is submitted to the utilization review agent at least\ntwenty-four hours prior to discharge from an inpatient admission\npursuant to this subsection, a utilization review agent shall not deny,\non the basis of medical necessity or lack of prior authorization,\ncoverage for the inpatient substance use disorder treatment while a\ndetermination by the utilization review agent is pending.\n * NB Effective April 1, 2015\n (d) A utilization review agent shall make a utilization review\ndetermination involving health care services which have been delivered\nwithin thirty days of receipt of the necessary information.\n (e) Notice of an adverse determination made by a utilization review\nagent shall be in writing and must include:\n (1) the reasons for the determination including the clinical\nrationale, if any;\n (2) instructions on how to initiate standard appeals and expedited\nappeals pursuant to section four thousand nine hundred four and an\nexternal appeal pursuant to section four thousand nine hundred fourteen\nof this article; and\n (3) 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. Such notice shall also specify what, if any,\nadditional necessary information must be provided to, or obtained by,\nthe utilization review agent in order to render a decision on the\nappeal.\n (f) In the event that a utilization review agent renders an adverse\ndetermination without attempting to discuss such matter with the\ninsured's health care provider who specifically recommended the health\ncare service, procedure or treatment under review, such health care\nprovider shall have the opportunity to request a reconsideration of the\nadverse determination. Except in cases of retrospective reviews, such\nreconsideration shall occur within one business day of receipt of the\nrequest and shall be conducted by the insured's health care provider and\nthe clinical peer reviewer making the initial determination or a\ndesignated clinical peer reviewer if the original clinical peer reviewer\ncannot be available. In the event that the adverse determination is\nupheld after reconsideration, the utilization review agent shall provide\nnotice as required pursuant to subsection (e) of this section. Nothing\nin this section shall preclude the insured from initiating an appeal\nfrom an adverse determination.\n (g) Failure by the utilization review agent to make a determination\nwithin the time periods prescribed in this section shall be deemed to be\nan adverse determination subject to appeal pursuant to section four\nthousand nine hundred four of this title.\n