NY Pub Health L § 4912 (2021)
2021 New York Laws PBH - Public Health Article 49 - Utilization Review and External Appeal Title 2 - Right to External Appeal 4912 - Standards for Certification.

§ 4912. Standards for certification. 1. The commissioner shall develop an  application  for  certification.  At  a  minimum,  applicants  shall provide:  (a) 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;  (b) 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;  (c) a description of the methods of recruiting and selecting impartial clinical peer reviewers and matching such reviewers to specific cases;  (d) 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;  (e) 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;  (f) a description of the quality assurance program established by  the external  appeal  agent  pursuant to paragraph (c) of subdivision two of this section;  (g)  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;  (h)  the  names  and  biographies  of  all  directors,  officers,  and executives of the external appeal agent;  (i)  an  experimental  and  investigational  treatment  review plan to conduct appeals  pursuant  to  subparagraph  (B)  of  paragraph  (d)  of subdivision  two  of  section forty-nine hundred fourteen of this title; and  (j) a description of the fees to be charged  by  agents  for  external appeals.   2.  The  commissioner  shall, at a minimum, require an external appeal agent to:  (a) 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;  (b)  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 forty-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 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;  (c) 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;  (d) 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;  (e) 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  (f) be accredited  by  a  nationally  recognized  private  accrediting organization.   3. 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:  (a) any national, state or local illness,  health  benefit  or  public advocacy group;  (b)  any national, state or local society or association of hospitals, physicians, or other providers of health care services; or  (c) any national, state or local association of health care plans.   4. A health care plan shall transmit, and  an  external  appeal  agent shall  be  authorized  to  receive and review, an enrollee's medical and treatment records in order to conduct an  external  appeal  pursuant  to this title.   5.  An  external  appeal  agent  shall  provide  ready  access  to the commissioner  to  all  data,  records,  and  information  collected  and maintained concerning such agent's external appeal activities.   6.  An  external  appeal agent shall agree to provide the commissioner such data, information,  and  reports  as  the  commissioner  determines necessary  to  evaluate the external appeal process established pursuant to this title.   7. The commissioner shall provide, upon the request of any  interested person,  a  copy  of  all  non-proprietary  information  filed  with the commissioner by the external appeal agent. The commissioner may charge a reasonable fee to the interested person for  reproducing  the  requested information.