2023 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.