NY Pub Health L § 4902 (2021)
2021 New York Laws PBH - Public Health Article 49 - Utilization Review and External Appeal Title 1 - Certification of Agents and Utilization Review Process 4902 - Utilization Review Programs Standards.

§  4902.  Utilization  review  program  standards. 1. Each utilization review agent  shall  adhere  to  utilization  review  program  standards consistent  with the provisions of this title which shall, at a minimum, include:  (a) 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;  (b) 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  enrollees 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   commissioner  and  the superintendent of financial services as required pursuant to subdivision five of section forty-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;  (c) Utilization of written clinical review criteria developed pursuant to a utilization review plan;  (d) 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 enrollee,  an enrollee's designee and/or an enrollee'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 enrollee;  (e)  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 forty-nine hundred four and an  external  appeal  pursuant  to  section  forty-nine hundred  fourteen of this article; and (iii) notice of the availability, upon request of the enrollee or the enrollee's designee, of the clinical review criteria relied upon to make such determination;  (f) 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 subdivision  three  of section forty-nine hundred three of this title or an expedited  appeal  filed  pursuant  to  subdivision  two  of  section  forty-nine  hundred  four  of  this  title, on a twenty-four hour a day, seven day a week basis;  (g)  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;  (h) Establishment of a requirement that emergency services rendered to an  enrollee  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.  (i) 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.  (j) 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 and the superintendent of financial services. Approved clinical review criteria shall  have  inter rater  reliability  testing  completed  by  December  thirty-first,  two thousand nineteen.  (k) Establishment of  a  requirement  that  emergency  department  and inpatient  hospital  services  rendered  by a general hospital certified pursuant to article twenty-eight of this chapter to an enrollee 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.   2. Each  utilization  review  agent  shall  assure  adherence  to  the requirements   stated   in  subdivision  one  of  this  section  by  all contractors, subcontractors, subvendors, agents and employees affiliated by contract or otherwise with such utilization review agent.   3. When establishing a step therapy  protocol,  a  utilization  review agent shall utilize recognized evidence-based and peer reviewed clinical review  criteria  that  takes into account the needs of atypical patient populations and diagnoses as well when establishing the clinical  review criteria.   4.  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 enrollee and the enrollee's medical condition.