NY Pub Health L § 4901 (2021)
2021 New York Laws PBH - Public Health Article 49 - Utilization Review and External Appeal Title 1 - Certification of Agents and Utilization Review Process 4901 - Registration of Utilization Review Agents.

§   4901.    Registration  of  utilization  review  agents.  1.  Every utilization review agent who conducts the practice of utilization review shall biennially  register  with  the  commissioner  and  report,  in  a statement  subscribed  and  affirmed  as  true  under  the  penalties of perjury, the information required pursuant to subdivision  two  of  this section.   2. Such report shall contain a description of the following:  (a) The utilization review plan;  (b) 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 this chapter or pursuant to article thirty-one of the mental hygiene law;  (c) The provisions by which an enrollee, the enrollee'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 enrollee, the enrollee's designee, and, in the case   of   an   adverse   determination   involving   a   retrospective determination, the enrollee's health care provider, is informed of their right to appeal adverse determinations;  (d) Procedures by which a decision on a request for utilization review for services requiring preauthorization  shall  comply  with  timeframes established pursuant to this title;  (e) 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;  (f)  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;  (g)  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;  (h)  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;  (i)  A  description  of  the mechanisms employed to assure that only a clinical peer reviewer shall render an adverse determination;  (j) 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 later than the next 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;  (k)  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;  (l)  A  copy  of  the  materials  to  be  disclosed  to an enrollee or prospective enrollee pursuant  to  this  title  and  section  forty-four hundred eight of this chapter;  (m) A description of the mechanisms employed by the utilization review agent to assure that all contractors, subcontractors, subvendors, agents and  employees affiliated by contract or otherwise with such utilization review agent will adhere to  the  standards  and  requirements  of  this title; and  (n)  A  list  of  the payors for which the utilization review agent is performing utilization review in this state.   3. Upon receipt  of  the  report,  the  commissioner  shall  issue  an acknowledgment of the filing.   4.  A registration issued under this title shall be valid for a period of not more than two years, and may be renewed for additional periods of not more than two years each.   5. A health maintenance  organization  licensed  pursuant  to  article forty-three  of  the insurance law or certified under article forty-four of this chapter shall not be  required  to  register  as  a  utilization review  agent,  provided  that  such health maintenance organization has otherwise provided the information required pursuant to subdivision  two of this section to the commissioner.   6.  The  clinical  review  criteria and standards contained within the utilization review plan and the list  of  payors  required  pursuant  to paragraph (n) of subdivision two of this section shall not be subject to disclosure  pursuant  to  the  provisions  of  article six of the public officers law.