2023 New York Laws › ISC - Insurance › Article 49 - Utilization Review and External Appeal › Title 1 - Registration of Agents and Review Process › 4905 - Required and Prohibited Practices.

§ 4905. Required and prohibited practices. (a) Each utilization review
agent  shall  have written procedures for assuring that patient-specific
information obtained during the process of utilization review will be:
(1) kept confidential in accordance with applicable state and  federal
laws; and
(2)  shared  only  with  the  insured,  the  insured's  designee,  the
insured's health care provider and those who are authorized  by  law  to
receive such information.
(b)  Summary  data shall not be considered confidential if it does not
provide information to allow identification of individual patients.
(c) Any health care professional who  makes  determinations  regarding
the  medical  necessity  of  health  care  services during the course of
utilization  review  shall  be  appropriately  licensed,  registered  or
certified.
(d)  A utilization review agent shall not, with respect to utilization
review activities, permit or provide compensation or anything  of  value
to its employees, agents, or contractors based on:
(1)  either a percentage of the amount by which a claim is reduced for
payment or the number of claims or the cost of services  for  which  the
person has denied authorization or payment; or
(2)  any  other  method  that  encourages  the rendering of an adverse
determination.
(e) If a health care service has been  specifically  preauthorized  or
approved  for  an  insured  by a utilization review agent, a utilization
review agent shall not pursuant to retrospective review revise or modify
the specific standards, criteria or procedures used for the  utilization
review  for procedures, treatment and services delivered to the insured,
during the same course of treatment.
(f) Utilization review shall not be conducted more frequently than  is
reasonably  required  to  assess  whether the health care services under
review are medically necessary.
(g)   When   making   prospective,   concurrent   and    retrospective
determinations,  utilization  review  agents  shall  collect  only  such
information as is necessary to make such  determination  and  shall  not
routinely require health care providers to numerically code diagnoses or
procedures  to  be  considered  for  certification  or routinely request
copies of medical records of all patients reviewed.  During  prospective
or  concurrent  review, copies of medical records shall only be required
when necessary to verify that the health care services subject  to  such
review  are  medically  necessary.  In such cases, only the necessary or
relevant sections of the medical record shall be required. A utilization
review agent may request copies of partial or complete  medical  records
retrospectively.
(h)  In  no  event  shall information be obtained from the health care
providers for the use of the utilization review agent by  persons  other
than   health   care  professionals,  medical  record  technologists  or
administrative personnel who have received appropriate training.
(i) The utilization  review  agent  shall  not  undertake  utilization
review  at  the site of the provision of health care services unless the
utilization review agent:
(1) Identifies himself or herself by name and the name of his  or  her
organization,  including  displaying  photographic  identification which
includes the name of the utilization review agent and clearly identifies
the individual as representative of the utilization review agent;
(2) Whenever possible, schedules review at least one business  day  in
advance with the appropriate health care provider;
(3)  If  requested by a health care provider, assures that the on-site
review staff register with the appropriate contact person, if available,

prior to requesting any clinical  information  or  assistance  from  the
health care provider; and
(4)  Obtains consent from the insured or the insured's designee before
interviewing the patient's family, or observing any health care  service
being provided to the insured.
(5)  This  subsection  shall  not  apply  to health care professionals
engaged in providing care or case management or making on-site discharge
decisions.
(j) A utilization review agent shall not base an adverse determination
on a refusal to consent to observing any health care service.
(k) A utilization review agent shall not base an adverse determination
on lack of reasonable access to a  health  care  provider's  medical  or
treatment  records  unless  the  utilization  review  agent has provided
reasonable  notice  to  the  insured,  the  insured's  designee  or  the
insured's  health  care  provider,  in  which  case  the insured must be
notified, and has complied with all provisions of subsection (i) of this
section.
(l) Neither the utilization review agent nor the entity for which  the
agent  provides utilization review shall take any action with respect to
a patient or a health care provider that is intended  to  penalize  such
insured,  the  insured's designee, or the insured's health care provider
for, or to discourage such  insured,  the  insured's  designee,  or  the
insured's  health  care  provider  from  undertaking  an appeal, dispute
resolution or judicial review of an adverse determination.
(m) In no event shall an insured, an insured's designee, an  insured's
health  care  provider,  any  other  health  care provider, or any other
person or entity be required to inform or contact the utilization review
agent prior to the provision  of  emergency  care,  including  emergency
treatment or emergency admission.
(n)  No contract or agreement between a utilization review agent and a
health care provider shall contain any clause purporting to transfer  to
the  health  care provider by indemnification or otherwise any liability
relating to activities, actions or omissions of the  utilization  review
agent as opposed to the health care provider.
(o)  A  health  care professional providing health care services to an
insured shall be prohibited from serving as the clinical  peer  reviewer
for  such  insured  in  connection  with  the health care services being
provided to the insured.