NY Ins L § 4912 (2021)
2021 New York Laws ISC - Insurance Article 49 - Utilization Review and External Appeal Title 2 - Right to External Appeal 4912 - 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;  (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; and  (6) be accredited  by  a  nationally  recognized  private  accrediting organization.  (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.