N.Y. Insurance Law § 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.