New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XVIII - External Appeals Of Adverse Determinations Of Health Care Plans › Part 410 - External Appeals Of Adverse Determinations Of Health Care Plans › Section 410.9 - 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 Insurance Law and with the
				  following:
(a) Insured 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 Insurance Law.
(b) If a health care plan requires
				information necessary to conduct a standard internal appeal pursuant to section 4904  of the Insurance Law, the health care
				plan shall notify the insured and the insured'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 insured and the insured'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 Insurance 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 insured 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
				Insurance 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 Insurance 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 insured;
(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 insured'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 insured 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
				insured to request an external appeal.