N.Y. Ins. Law § 4904

§ 4904. Appeal of adverse determinations by utilization review agents.\n(a) An insured, the insured's designee and, in connection with\nretrospective adverse determinations, an insured's health care provider,\nmay appeal an adverse determination rendered by a utilization review\nagent.\n (a-1) An insured or the insured's designee may appeal an\nout-of-network denial by a health care plan by submitting: (1) a written\nstatement from the insured's attending physician, who must be a\nlicensed, board certified or board eligible physician qualified to\npractice in the specialty area of practice appropriate to treat the\ninsured for the health services sought, that the requested\nout-of-network health service is materially different from the health\nservice the health care plan approved to treat the insured's health care\nneeds; and (2) two documents from the available medical and scientific\nevidence, that the out-of-network health service is likely to be more\nclinically beneficial to the insured than the alternate recommended\nin-network health service and for which the adverse risk of the\nrequested health service would likely not be substantially increased\nover the in-network health service.\n * (a-2) An insured or the insured's designee may appeal an\nout-of-network referral denial by a health care plan by submitting a\nwritten statement from the insured's attending physician, who must be a\nlicensed, board certified or board eligible physician qualified to\npractice in the specialty area of practice appropriate to treat the\ninsured for the health service sought, provided that: (1) the in-network\nhealth care provider or providers recommended by the health care plan do\nnot have the appropriate training and experience to meet the particular\nhealth care needs of the insured for the health service; and (2)\nrecommends an out-of-network provider with the appropriate training and\nexperience to meet the particular health care needs of the insured, and\nwho is able to provide the requested health service.\n * NB Effective March 31, 2015\n * (b) A utilization review agent shall establish an expedited appeal\nprocess for appeal of an adverse determination involving (1) continued\nor extended health care services, procedures or treatments or additional\nservices for an insured undergoing a course of continued treatment\nprescribed by a health care provider or home health care services\nfollowing discharge from an inpatient hospital admission pursuant to\nsubsection (c) of section four thousand nine hundred three of this\narticle or (2) an adverse determination in which the health care\nprovider believes an immediate appeal is warranted except any\nretrospective determination. Such process shall include mechanisms which\nfacilitate resolution of the appeal including but not limited to the\nsharing of information from the insured's health care provider and the\nutilization review agent by telephonic means or by facsimile. The\nutilization review agent shall provide reasonable access to its clinical\npeer reviewer within one business day of receiving notice of the taking\nof an expedited appeal. Expedited appeals shall be determined within two\nbusiness days of receipt of necessary information to conduct such\nappeal. Expedited appeals which do not result in a resolution\nsatisfactory to the appealing party may be further appealed through the\nstandard appeal process, or through the external appeal process pursuant\nto section four thousand nine hundred fourteen of this article as\napplicable.\n * NB Effective until April 1, 2015\n * (b) A utilization review agent shall establish an expedited appeal\nprocess for appeal of an adverse determination involving (1) continued\nor extended health care services, procedures or treatments or additional\nservices for an insured undergoing a course of continued treatment\nprescribed by a health care provider or home health care services\nfollowing discharge from an inpatient hospital admission pursuant to\nsubsection (c) of section four thousand nine hundred three of this\narticle or (2) an adverse determination in which the health care\nprovider believes an immediate appeal is warranted except any\nretrospective determination. Such process shall include mechanisms which\nfacilitate resolution of the appeal including but not limited to the\nsharing of information from the insured's health care provider and the\nutilization review agent by telephonic means or by facsimile. The\nutilization review agent shall provide reasonable access to its clinical\npeer reviewer within one business day of receiving notice of the taking\nof an expedited appeal. Expedited appeals shall be determined within two\nbusiness days of receipt of necessary information to conduct such appeal\nexcept, with respect to inpatient substance use disorder treatment\nprovided pursuant to paragraph three of subsection (c) of section four\nthousand nine hundred three of this article, expedited appeals shall be\ndetermined within twenty-four hours of receipt of such appeal. Expedited\nappeals which do not result in a resolution satisfactory to the\nappealing party may be further appealed through the standard appeal\nprocess, or through the external appeal process pursuant to section four\nthousand nine hundred fourteen of this article as applicable. Provided\nthat the insured or the insured's health care provider files an\nexpedited internal and external appeal within twenty-four hours from\nreceipt of an adverse determination for inpatient substance use disorder\ntreatment for which coverage was provided while the initial utilization\nreview determination was pending pursuant to paragraph three of\nsubsection (c) of section four thousand nine hundred three of this\narticle, a utilization review agent shall not deny on the basis of\nmedical necessity or lack of prior authorization such substance use\ndisorder treatment while a determination by the utilization review agent\nor external appeal agent is pending.\n * NB Effective April 1, 2015\n (c) A utilization review agent shall establish a standard appeal\nprocess which includes procedures for appeals to be filed in writing or\nby telephone. A utilization review agent must establish a period of no\nless than forty-five days after receipt of notification by the insured\nof the initial utilization review determination and receipt of all\nnecessary information to file the appeal from said determination. The\nutilization review agent must provide written acknowledgment of the\nfiling of the appeal to the appealing party within fifteen days of such\nfiling and shall make a determination with regard to the appeal within\nsixty days of the receipt of necessary information to conduct the\nappeal. The utilization review agent shall notify the insured, the\ninsured's designee and, where appropriate, the insured's health care\nprovider, in writing of the appeal determination within two business\ndays of the rendering of such determination.\n The notice of the appeal determination shall include:\n (1) the reasons for the determination; provided, however, that where\nthe adverse determination is upheld on appeal, the notice shall include\nthe clinical rationale for such determination; and\n (2) a notice of the insured's right to an external appeal together\nwith a description, 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 external appeals.\n (d) Both expedited and standard appeals shall only be conducted by\nclinical peer reviewers, provided that any such appeal shall be reviewed\nby a clinical peer reviewer other than the clinical peer reviewer who\nrendered the adverse determination.\n (e) Failure by the utilization review agent to make a determination\nwithin the applicable time periods in this section shall be deemed to be\na reversal of the utilization review agent's adverse determination.\n