NY Ins L § 4902 (2021)
2021 New York Laws ISC - Insurance Article 49 - Utilization Review and External Appeal Title 1 - Registration of Agents and Review Process 4902 - Utilization Review Program Standards.

§  4902.  Utilization  review  program standards. (a) Each utilization review agent  shall  adhere  to  utilization  review  program  standards consistent  with the provisions of this title which shall, at a minimum, include:  (1) Appointment of a medical director, who is  a  licensed  physician; provided,  however,  that  the  utilization  review  agent may appoint a clinical director  when  the  utilization  review  performed  is  for  a discrete  category  of health care service and provided further that the clinical director is a licensed health care professional  who  typically manages  the  category  of  service.  Responsibilities  of  the  medical director, or, where appropriate, the clinical director,  shall  include, but  not be limited to, the supervision and oversight of the utilization review process;  (2) Development of written policies and  procedures  that  govern  all aspects  of  the  utilization  review  process  and a requirement that a utilization review agent shall maintain and make available  to  insureds and  health  care  providers  a  written  description of such procedures including procedures to appeal an adverse determination together with  a description,   jointly   promulgated   by  the  superintendent  and  the commissioner of health as required pursuant to subsection (e) of section four thousand nine hundred fourteen of this  article,  of  the  external appeal process established pursuant to title two of this article and the time frames for such appeals;  (3) Utilization of written clinical review criteria developed pursuant to a utilization review plan;  (4)  Establishment  of  a  process  for  rendering  utilization review determinations which shall, at a minimum, include: written procedures to assure that utilization reviews and determinations are conducted  within the  timeframes  established herein; procedures to notify an insured, an insured's designee and/or an insured's health care provider  of  adverse determinations;  and  procedures  for  appeal  of adverse determinations including the establishment of an expedited appeals process for  denials of continued inpatient care or where there is imminent or serious threat to the health of the insured;  (5)  Establishment of a written procedure to assure that the notice of an adverse determination includes:  (i)  the  reasons  for  the  determination  including   the   clinical rationale, if any;  (ii)  instructions  on  how to initiate standard and expedited appeals pursuant to section four thousand nine hundred four of this article  and an  external  appeal  pursuant  to  section  four  thousand nine hundred fourteen of this article; and  (iii) notice of the availability, upon request of the insured  or  the insured's  designee, of the clinical review criteria relied upon to make such determination;  (6) Establishment of a requirement 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;  (7) Establishment of appropriate policies  and  procedures  to  ensure that   all   applicable   state   and   federal   laws  to  protect  the confidentiality of individual medical records are followed;  (8) Establishment of a requirement that emergency services rendered to an insured shall  not  be  subject  to  prior  authorization  nor  shall reimbursement  for  such  services  be  denied  on retrospective review; provided,  however,  that  such  services  are  medically  necessary  to stabilize or treat an emergency condition.  (9)  When  conducting  utilization  review for purposes of determining health care coverage for substance use disorder treatment, a utilization review agent shall utilize an evidence-based and peer reviewed  clinical review  tool  that  is  appropriate  to  the  age  of  the patient. When conducting such utilization review for treatment provided in this state, a utilization review agent shall  utilize  an  evidence-based  and  peer reviewed  clinical  tool  designated  by  the  office  of alcoholism and substance abuse services that is consistent with the  treatment  service levels  within  the  office  of  alcoholism and substance abuse services system. All approved tools shall have inter  rater  reliability  testing completed by December thirty-first, two thousand sixteen.   10.  When  establishing  a step therapy protocol, a utilization review agent shall utilize recognized evidence-based and peer reviewed clinical review criteria that also takes  into  account  the  needs  of  atypical patient  populations and diagnoses when establishing the clinical review criteria.   11. When conducting utilization review for  a  step  therapy  protocol override  determination,  a  utilization  review agent shall utilize, in addition  to  any  other  requirements  of  this   article,   recognized evidence-based  and  peer  reviewed  clinical  review  criteria  that is appropriate for the insured and the insured's medical condition.  (12) When conducting utilization review for  purposes  of  determining health care coverage for a mental health condition, a utilization review agent  shall  utilize  evidence-based  and peer reviewed clinical review criteria that is appropriate to the age of the patient. The  utilization review  agent  shall use clinical review criteria deemed appropriate and approved for such use by  the  commissioner  of  the  office  of  mental health,  in  consultation  with  the  commissioner  of  health  and  the superintendent. Approved clinical review criteria shall have inter rater reliability testing completed by  December  thirty-first,  two  thousand nineteen.  (13)  Establishment  of  a  requirement  that emergency department and inpatient hospital services rendered by  a  general  hospital  certified pursuant  to article twenty-eight of the public health law to an insured to treat COVID-19 during a declared state disaster emergency related  to COVID-19  shall  not be denied on retrospective review on the basis that such services were not medically necessary.  (b) Each utilization  review  agent  shall  assure  adherence  to  the requirements   stated   in   subsection  (a)  of  this  section  by  all contractors, subcontractors, subvendors, agents and employees affiliated by contract or otherwise with such utilization review agent.