NY Ins L § 4901 (2021)
2021 New York Laws ISC - Insurance Article 49 - Utilization Review and External Appeal Title 1 - Registration of Agents and Review Process 4901 - Reporting Requirements for Utilization Review Agents.

§  4901.  Reporting  requirements  for  utilization review agents. (a) Every  utilization  review  agent  shall  biennially   report   to   the superintendent  of  financial  services,  in  a statement subscribed and affirmed as  true  under  the  penalties  of  perjury,  the  information required pursuant to subsection (b) of this section.  (b) Such report shall contain a description of the following:  (1) The utilization review plan;  (2) Those circumstances, if any, under which utilization review may be delegated  to  a  utilization  review  program  conducted  by a facility licensed pursuant to article twenty-eight of the public  health  law  or pursuant to article thirty-one of the mental hygiene law;  (3)  The  provisions by which an insured, the insured's designee, or a health care provider may seek reconsideration of or appeal from  adverse determinations  by  the utilization review agent, in accordance with the provisions of this title, including provisions to ensure a timely appeal and that an insured, the insured's designee, and,  in  the  case  of  an adverse  determination  involving  a  retrospective  determination,  the insured's health care provider is informed  of  their  right  to  appeal adverse determinations;  (4) Procedures by which a decision on a request for utilization review for  services  requiring  preauthorization  shall comply with timeframes established pursuant to this title;  (5) A description of an emergency care policy, which shall include the procedures under which an emergency admission shall be made or emergency treatment shall be given;  (6) A description of the personnel  utilized  to  conduct  utilization review   including  a  description  of  the  circumstances  under  which utilization review may be conducted by:  (i) administrative personnel;  (ii) health care professionals who are not  clinical  peer  reviewers; and  (iii) clinical peer reviewers;  (7)   A   description  of  the  mechanisms  employed  to  assure  that administrative personnel are trained in the principles and procedures of intake screening and data collection and are appropriately monitored  by a  licensed  health care professional while performing an administrative review;  (8) A description of the mechanisms employed  to  assure  that  health care professionals conducting utilization review are:  (i) appropriately licensed, registered or certified; and  (ii)  trained  in  the  principles,  procedures  and standards of such utilization review agent.  (9) A description of the mechanisms employed to  assure  that  only  a clinical peer reviewer shall render an adverse determination;  (10)   Provisions   to   ensure  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;  (11)  The  policies and procedures to ensure that all applicable state and federal laws to protect the confidentiality  of  individual  medical and treatment records are followed;  (12)  A  copy  of  the  materials  to  be  disclosed  to an insured or prospective insured pursuant to  sections  three  thousand  two  hundred seventeen-a  or four thousand three hundred twenty-four of this chapter, whichever is applicable, and this title;  (13) A description of  the  mechanisms  employed  by  the  utilization review  agent  to  assure that all subcontractors, subvendors, agents or employees affiliated by contract  or  otherwise  with  such  utilization review  agent  will  adhere  to  the  standards and requirements of this title; and  (c) The clinical review criteria and standards  contained  within  the utilization  review  plan shall not be subject to disclosure pursuant to the provisions of article six of the public officers law.