New York Laws
PBH - Public Health
Article 49 - Utilization Review and External Appeal

Title 1 - Certification of Agents and Utilization Review Process

4900 - Definitions. - (a) for purposes of title one of this article: (i)...

4901 - Registration of Utilization Review Agents. - (a) The utilization review plan; (b) Those circumstances, if any,...

4902 - Utilization Review Programs Standards. - (a) Appointment of a medical director, who is a licensed...

4903 - Utilization Review Determinations. - (a) Administrative personnel trained in the principles and procedures of...

4903-A - Utilization Review Determinations for Medically Fragile Children. - (a) Consider as medically necessary all covered services that assist...

4904 - Appeal of Adverse Determinations by Utilization Review Agents. - (a) continued or extended health care services, procedures or treatments...

4905 - Required and Prohibited Practices. - (a) kept confidential in accordance with applicable state and federal...

4906 - Waiver. - § 4906. Waiver. 1. Any agreement which purports to waive,...

4907 - Rights and Remedies. - § 4907. Rights and remedies. The rights and remedies conferred...

4908 - Applicability to Erisa Plans. - § 4908. Applicability to ERISA Plans. Notwithstanding the foregoing, the...

4909 - Site of Service Clinical Review. - (a) "Free-standing ambulatory surgical center" shall mean a diagnostic and...

Title 2 - Right to External Appeal

4910 - Right to External Appeal Established. - (a) (i) the enrollee has had coverage of a health...

4911 - Powers of the Commissioner. - § 4911. Powers of the commissioner. 1. The commissioner shall...

4912 - Standards for Certification. - (a) a description of the qualifications of the clinical peer...

4913 - Conflict of Interest. - (a) the health care plan; (b) any officer, director, or...

4914 - Procedures for External Appeals of Adverse Determinations. - (b) The external appeal agent shall make a determination with...

4915 - Prohibited Practices. - § 4915. Prohibited practices. An external appeal agent shall not,...

4916 - Oversight and Surveillance of the External Appeal Process. - (a) review the activities of the health care plans and...

4917 - Hold Harmless. - § 4917. Hold harmless. A health care provider requesting an...