§ 4912 — Standards for certification

§ 4912. Standards for certification. (a) The superintendent shall\ndevelop an application for certification. At a minimum, applicants shall\nprovide:\n (1) a description of the qualifications of the clinical peer reviewers\nretained to conduct external appeals of final adverse determinations\nincluding such reviewers' current and past employment history and\npractice affiliations;\n (2) a description of the procedures employed to ensure that clinical\npeer reviewers conducting external appeals are:\n (i) appropriately licensed, registered or certified;\n (ii) trained in the principles, procedures and standards of the\nexternal appeal agent; and\n (iii) knowledgeable about the health care service which is the subject\nof the final adverse determination under appeal;\n (3) a description of the methods of recruiting and selecting impartial\nclinical peer reviewers and matching such reviewers to specific cases;\n (4) the number of clinical peer reviewers retained by the external\nappeal agent, and a description of the areas of expertise available from\nsuch reviewers and the types of cases such reviewers are qualified to\nreview;\n (5) a description of the policies and procedures employed to protect\nthe confidentiality of individual medical and treatment records in\naccordance with applicable state and federal laws;\n (6) a description of the quality assurance program established by the\nexternal appeal agent pursuant to paragraph three of subsection (b) of\nthis section;\n (7) the names of all corporations and organizations owned or\ncontrolled by the external appeal agent, or which owns or controls such\nagent, and the nature and extent of any such ownership or control;\n (8) the names and biographies of all directors, officers, and\nexecutives of the external appeal agent;\n (9) an experimental and investigational treatment review plan to\nconduct appeals pursuant to subparagraph (B) of paragraph four of\nsubsection (b) of section four thousand nine hundred fourteen of this\ntitle; and\n (10) a description of the fees to be charged by agents for external\nappeals.\n (b) The superintendent shall, at a minimum, require an external appeal\nagent to:\n (1) appoint a medical director, who is a physician in possession of a\ncurrent and valid non-restricted license to practice medicine. Such\ndirector shall be responsible for the supervision and oversight of the\nexternal appeal process;\n (2) develop written policies and procedures governing all aspects of\nthe appeal process, including, at a minimum:\n (i) procedures to ensure that appeals are conducted within the time\nframes specified in section four thousand nine hundred fourteen of this\ntitle, and any required notices are provided in a timely manner;\n (ii) procedures to ensure the selection of qualified and impartial\nclinical peer reviewers. Such reviewers shall be qualified to render and\nimpartial determinations relating to the health care service which is\nthe subject of the final adverse determination under appeal;\n (iii) procedures to ensure the confidentiality of medical and\ntreatment records and review materials; and\n (iv) procedures to ensure adherence to the requirements of this title\nby any contractor, subcontractor, subvendor, agent or employee\naffiliated by contract or otherwise with such external appeal agent;\n (3) establish a quality assurance program. Such program shall include\nwritten descriptions, to be provided to all individuals involved in such\nprogram, of the organizational arrangements and ongoing procedures for\nthe identification, evaluation, resolution and follow-up of potential\nand actual problems in external appeals performed by the external appeal\nagent and to ensure the maintenance of program standards pursuant to\nthis section;\n (4) establish a toll-free telephone service to receive information on\na 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant\nto this title. Such system shall be capable of accepting, recording or\nproviding instruction to incoming telephone calls during other than\nnormal business hours;\n (5) develop procedures to ensure that:\n (i) appropriate personnel are reasonably accessible not less than\nforty hours per week during normal business hours to discuss patient\ncare and to allow response to telephone requests, and\n (ii) response to accepted or recorded messages shall be made not less\nthan one business day after the date on which the call was received; and\n (6) be accredited by a nationally recognized private accrediting\norganization.\n (c) No entity shall be qualified to submit such request for\napplication if it owns or controls, is owned or controlled by, or\nexercises common control with, any of the following:\n (1) any national, state or local illness, health benefit or public\nadvocacy group;\n (2) any national, state or local society or association of hospitals,\nphysicians, or other providers of health care services; or\n (3) any national, state or local association of health care plans.\n (d) A health care plan shall transmit, and an external appeal agent\nshall be authorized to receive and review, an insured's medical and\ntreatment records in order to conduct an external appeal pursuant to\nthis title.\n (e) An external appeal agent shall provide ready access to the\nsuperintendent to all data, records, and information collected and\nmaintained concerning such agent's external appeal activities.\n (f) An external appeal agent shall agree to provide the superintendent\nsuch data, information, and reports as the superintendent determines\nnecessary to evaluate the external appeal process established pursuant\nto this title.\n (g) The superintendent shall provide, upon the request of any\ninterested person, a copy of all non-proprietary information filed with\nthe superintendent by the external appeal agent. The superintendent may\ncharge a reasonable fee to the interested person for reproducing the\nrequested information.\n