2023 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.