2023 New York Laws › ISC - Insurance › Article 49 - Utilization Review and External Appeal › Title 2 - Right to External Appeal › 4912 - Standards for Certification.

§  4912.  Standards  for  certification.  (a) The superintendent shall
develop an application for certification. At a minimum, applicants shall
provide:
(1) 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;
(2) 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;
(3) a description of the methods of recruiting and selecting impartial
clinical peer reviewers and matching such reviewers to specific cases;
(4) 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;
(5) 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;
(6) a description of the quality assurance program established by  the
external  appeal  agent pursuant to paragraph three of subsection (b) of
this section;
(7)  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;
(8)  the  names  and  biographies  of  all  directors,  officers,  and
executives of the external appeal agent;
(9)  an  experimental  and  investigational  treatment  review plan to
conduct appeals pursuant  to  subparagraph  (B)  of  paragraph  four  of
subsection  (b)  of  section four thousand nine hundred fourteen of this
title; and
(10) a description of the fees to be charged by  agents  for  external
appeals.
(b) The superintendent shall, at a minimum, require an external appeal
agent to:
(1)  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;
(2) 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 four thousand 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 and
impartial 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;
(3) 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;
(4) 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;
(5) 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
(6) be accredited  by  a  nationally  recognized  private  accrediting
organization.
(c)   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:
(1)  any  national,  state  or local illness, health benefit or public
advocacy group;
(2) any national, state or local society or association of  hospitals,
physicians, or other providers of health care services; or
(3) any national, state or local association of health care plans.
(d)  A  health  care plan shall transmit, and an external appeal agent
shall be authorized to receive and  review,  an  insured's  medical  and
treatment  records  in  order  to conduct an external appeal pursuant to
this title.
(e) An external  appeal  agent  shall  provide  ready  access  to  the
superintendent  to  all  data,  records,  and  information collected and
maintained concerning such agent's external appeal activities.
(f) An external appeal agent shall agree to provide the superintendent
such data, information, and reports  as  the  superintendent  determines
necessary  to  evaluate the external appeal process established pursuant
to this title.
(g)  The  superintendent  shall  provide,  upon  the  request  of  any
interested  person, a copy of all non-proprietary information filed with
the superintendent by the external appeal agent. The superintendent  may
charge  a  reasonable  fee  to the interested person for reproducing the
requested information.