N.Y. Insurance Law § 4901: Reporting requirements for utilization review agents

§ 4901. Reporting requirements for utilization review agents. (a)

Every utilization review agent shall biennially report to the

superintendent of financial services, in a statement subscribed and

affirmed as true under the penalties of perjury, the information

required pursuant to subsection (b) of this section.

(b) Such report shall contain a description of the following:

(1) The utilization review plan;

(2) 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 the public health law or

pursuant to article thirty-one of the mental hygiene law;

(3) The provisions by which an insured, the insured'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 insured, the insured's designee, and, in the case of an

adverse determination involving a retrospective determination, the

insured's health care provider is informed of their right to appeal

adverse determinations;

(4) Procedures by which a decision on a request for utilization review

for services requiring preauthorization shall comply with timeframes

established pursuant to this title;

(5) 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;

(6) 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;

(7) 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;

(8) 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.

(9) A description of the mechanisms employed to assure that only a

clinical peer reviewer shall render an adverse determination;

(10) 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 less than one 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

subsection (a) of section four thousand nine hundred three of this title

or an expedited appeal filed pursuant to subsection (b) of section four

thousand nine hundred four of this title, on a twenty-four hour a day,

seven day a week basis;

(11) 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;

(12) A copy of the materials to be disclosed to an insured or

prospective insured pursuant to sections three thousand two hundred

seventeen-a or four thousand three hundred twenty-four of this chapter,

whichever is applicable, and this title;

(13) A description of the mechanisms employed by the utilization

review agent to assure that all subcontractors, subvendors, agents or

employees affiliated by contract or otherwise with such utilization

review agent will adhere to the standards and requirements of this

title; and

(c) The clinical review criteria and standards contained within the

utilization review plan shall not be subject to disclosure pursuant to

the provisions of article six of the public officers law.