New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.9 - Responsibilities of health care plans

Current through Register Vol. 46, No. 28, July 10, 2024
Health care plans shall be responsible for compliance
						with all applicable requirements of article 49 of the Public Health Law and
						with the following:
(a) Enrollee
					 requests for experimental or investigational health care services that would
					 otherwise be a covered benefit except for the health care plan's determination
					 that the health care service is experimental or investigational shall be
					 subject to utilization review pursuant to title I of article 49 of the Public
					 Health Law.
(b) If a health care
					 plan requires information necessary to conduct a standard internal appeal
					 pursuant to section 4904  of the Public Health Law, the health
					 care plan shall notify the enrollee and the enrollee's health care provider, in
					 writing, within 15 days of receipt of the appeal, to identify and request the
					 necessary information. In the event that only a portion of such necessary
					 information is received, the health care plan shall request the missing
					 information, in writing, within five business days of receipt of the partial
					 information. In the case of expedited appeals, the health care plan shall
					 immediately notify the enrollee and the enrollee's health care provider by
					 telephone or facsimile to identify and request the necessary information,
					 followed by written notification. The period of time to make an appeal
					 determination under section 4904  of the Public Health Law begins upon a
					 health care plan's receipt of necessary information.
(c) If a health care plan offers two levels
					 of internal appeals, the health care plan may not require the enrollee to
					 exhaust the second level of internal appeal to be eligible for an external
					 appeal.
(d) Notices of final
					 adverse determinations shall comply with all requirements of article 49 of the
					 Public Health Law and with all applicable Federal laws and rules.
(e) Each notice of a final adverse
					 determination of an expedited or standard utilization review appeal under
					 section 4904  of the Public Health Law shall be in
					 writing, dated and include the following:
(1)
					 a clear statement describing the basis and clinical rationale for the denial as
					 applicable to the enrollee;
(2) a
					 clear statement that the notice constitutes the final adverse
					 determination;
(3) the health care
					 plan's contact person and his or her telephone number;
(4) the enrollee's coverage type;
(5) the name and full address of the health
					 care plan's utilization review agent;
(6) the utilization review agent's contact
					 person and his or her telephone number;
(7) a description of the health care service
					 that was denied, including, as applicable and available, the dates of service,
					 the name of the facility and/or physician proposed to provide the treatment and
					 the developer/manufacturer of the health care service;
(8) a statement that the enrollee may be
					 eligible for an external appeal and the time frames for requesting an appeal;
					 and
(9) for health care plans that
					 offer two levels of internal appeals, a clear statement written in bolded text
					 that the 45-day time frame for requesting an external appeal begins upon
					 receipt of the final adverse determination of the first level appeal,
					 regardless of whether or not a second level appeal is requested, and that by
					 choosing to request a second level internal appeal, the time may expire for the
					 enrollee to request an external appeal.