§ 4901 — Registration of utilization review agents

New York § 4901

• Jurisdiction: New York
• Law PBH: Public Health
• Title 1: Certification of Agents and Utilization Review Process
• Art. 49: Utilization Review and External Appeal

Text

§ 4901. Registration of utilization review agents. 1. Every\nutilization review agent who conducts the practice of utilization review\nshall biennially register with the commissioner and report, in a\nstatement subscribed and affirmed as true under the penalties of\nperjury, the information required pursuant to subdivision two of this\nsection.\n 2. Such report shall contain a description of the following:\n (a) The utilization review plan;\n (b) Those circumstances, if any, under which utilization review may be\ndelegated to a utilization review program conducted by a facility\nlicensed pursuant to article twenty-eight of this chapter or pursuant to\narticle thirty-one of the mental hygiene law;\n (c) The provisions by which an enrollee, the enrollee's designee, or a\nhealth care provider may seek reconsideration of, or appeal from,\nadverse determinations by the utilization review agent, in accordance\nwith the provisions of this title, including provisions to ensure a\ntimely appeal and that an enrollee, the enrollee's designee, and, in the\ncase of an adverse determination involving a retrospective\ndetermination, the enrollee's health care provider, is informed of their\nright to appeal adverse determinations;\n (d) Procedures by which a decision on a request for utilization review\nfor services requiring preauthorization shall comply with timeframes\nestablished pursuant to this title;\n (e) A description of an emergency care policy, which shall include the\nprocedures under which an emergency admission shall be made or emergency\ntreatment shall be given;\n (f) A description of the personnel utilized to conduct utilization\nreview including a description of the circumstances under which\nutilization review may be conducted by:\n (i) administrative personnel,\n (ii) health care professionals who are not clinical peer reviewers,\nand\n (iii) clinical peer reviewers;\n (g) A description of the mechanisms employed to assure that\nadministrative personnel are trained in the principles and procedures of\nintake screening and data collection and are appropriately monitored by\na licensed health care professional while performing an administrative\nreview;\n (h) A description of the mechanisms employed to assure that health\ncare professionals conducting utilization review are:\n (i) appropriately licensed, registered or certified; and\n (ii) trained in the principles, procedures and standards of such\nutilization review agent;\n (i) A description of the mechanisms employed to assure that only a\nclinical peer reviewer shall render an adverse determination;\n (j) Provisions to ensure that appropriate personnel of the utilization\nreview agent are reasonably accessible by toll-free telephone:\n (i) not less than forty hours per week during normal business hours,\nto discuss patient care and allow response to telephone requests, and to\nensure that such utilization review agent has a telephone system capable\nof accepting, recording or providing instruction to incoming telephone\ncalls during other than normal business hours and to ensure response to\naccepted or recorded messages not later than the next business day after\nthe date on which the call was received; or\n (ii) notwithstanding the provisions of subparagraph (i) of this\nparagraph, not less than forty hours per week during normal business\nhours, to discuss patient care and allow response to telephone requests,\nand to ensure that, in the case of a request submitted pursuant to\nsubdivision three of section forty-nine hundred three of this title or\nan expedited appeal filed pursuant to subdivision two of section\nforty-nine hundred four of this title, on a twenty-four hour a day,\nseven day a week basis;\n (k) The policies and procedures to ensure that all applicable state\nand federal laws to protect the confidentiality of individual medical\nand treatment records are followed;\n (l) A copy of the materials to be disclosed to an enrollee or\nprospective enrollee pursuant to this title and section forty-four\nhundred eight of this chapter;\n (m) A description of the mechanisms employed by the utilization review\nagent to assure that all contractors, subcontractors, subvendors, agents\nand employees affiliated by contract or otherwise with such utilization\nreview agent will adhere to the standards and requirements of this\ntitle; and\n (n) A list of the payors for which the utilization review agent is\nperforming utilization review in this state.\n 3. Upon receipt of the report, the commissioner shall issue an\nacknowledgment of the filing.\n 4. A registration issued under this title shall be valid for a period\nof not more than two years, and may be renewed for additional periods of\nnot more than two years each.\n 5. A health maintenance organization licensed pursuant to article\nforty-three of the insurance law or certified under article forty-four\nof this chapter shall not be required to register as a utilization\nreview agent, provided that such health maintenance organization has\notherwise provided the information required pursuant to subdivision two\nof this section to the commissioner.\n 6. The clinical review criteria and standards contained within the\nutilization review plan and the list of payors required pursuant to\nparagraph (n) of subdivision two of this section shall not be subject to\ndisclosure pursuant to the provisions of article six of the public\nofficers law.\n