2023 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) (i) Establishment of a written procedure to assure that the notice
of   an   adverse  determination  includes:  (1)  the  reasons  for  the
determination including the clinical rationale, if any; (2) 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;  (3)  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;
(4)  what, if any, additional necessary information must be provided to,
or obtained by, the utilization  review  agent  in  order  to  render  a
decision on an appeal; and (5) for an adverse determination related to a
step  therapy protocol override determination, information that includes
the clinical review criteria relied upon to make such determination  and
any  applicable  alternative  prescription  drugs  subject  to  the step
therapy protocol of the utilization review agent.
(ii) A utilization review agent  may  provide  notice  of  an  adverse
determination  related to a step therapy protocol override determination
electronically  pursuant  to  subdivision  nine  of  section  forty-nine
hundred three of this title, including by electronic mail or through the
health  care  plan's  member  portal  and provider portal. An electronic
notice of such an adverse determination may  meet  the  requirements  of
clause  five  of  subparagraph  (i)  of  this  paragraph  by  linking to
information posted on the website of the health care plan;
(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.
(l) The commissioner,  in  consultation  with  the  superintendent  of
financial  services, may, as necessary, promulgate by regulation special
considerations and processes for utilization review related to medically
fragile  children.  Such  regulations  may  include,   at   a   minimum,
considerations and processes related to:
(i)   medically   necessary  covered  services  to  medically  fragile
children;
(ii)  determinations  specific  to  the  needs  of  medically  fragile
children;
(iii) stabilization and discharge plans; and
(iv) payment for the care of medically fragile children.
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.