New York Laws
Title 1 - Registration of Agents and Review Process
4901 - Reporting Requirements for Utilization Review Agents.

(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.