Section 4902. Utilization review program standards

(a) Each utilization
  review agent  shall  adhere  to  utilization  review  program  standards
  consistent  with the provisions of this title which shall, at a minimum,
  include:
    (1) Appointment of a medical director, who is  a  licensed  physician;
  provided,  however,  that  the  utilization  review  agent may appoint a
  clinical director  when  the  utilization  review  performed  is  for  a
  discrete  category  of health care service and provided further that the
  clinical director is a licensed health care professional  who  typically
  manages  the  category  of  service.  Responsibilities  of  the  medical
  director, or, where appropriate, the clinical director,  shall  include,
  but  not be limited to, the supervision and oversight of the utilization
  review process;
    (2) Development of written policies and  procedures  that  govern  all
  aspects  of  the  utilization  review  process  and a requirement that a
  utilization review agent shall maintain and make available  to  insureds
  and  health  care  providers  a  written  description of such procedures
  including procedures to appeal an adverse determination together with  a
  description,   jointly   promulgated   by  the  superintendent  and  the
  commissioner of health as required pursuant to subsection (e) of section
  four thousand nine hundred fourteen of this  article,  of  the  external
  appeal process established pursuant to title two of this article and the
  time frames for such appeals;
    (3) Utilization of written clinical review criteria developed pursuant
  to a utilization review plan;
    (4)  Establishment  of  a  process  for  rendering  utilization review
  determinations which shall, at a minimum, include: written procedures to
  assure that utilization reviews and determinations are conducted  within
  the  timeframes  established herein; procedures to notify an insured, an
  insured's designee and/or an insured's health care provider  of  adverse
  determinations;  and  procedures  for  appeal  of adverse determinations
  including the establishment of an expedited appeals process for  denials
  of continued inpatient care or where there is imminent or serious threat
  to the health of the insured;
    (5)  Establishment of a written procedure to assure that the notice of
  an adverse determination includes:
    (i)  the  reasons  for  the  determination  including   the   clinical
  rationale, if any;
    (ii)  instructions  on  how to initiate standard and expedited appeals
  pursuant to section four thousand nine hundred four of this article  and
  an  external  appeal  pursuant  to  section  four  thousand nine hundred
  fourteen of this article; and
    (iii) notice of the availability, upon request of the insured  or  the
  insured's  designee, of the clinical review criteria relied upon to make
  such determination;
    (6) Establishment of a requirement 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;
    (7) Establishment of appropriate policies  and  procedures  to  ensure
  that   all   applicable   state   and   federal   laws  to  protect  the
  confidentiality of individual medical records are followed;
    (8) Establishment of a requirement that emergency services rendered to
  an insured shall  not  be  subject  to  prior  authorization  nor  shall
  reimbursement  for  such  services  be  denied  on retrospective review;
  provided,  however,  that  such  services  are  medically  necessary  to
  stabilize or treat an emergency condition.
    (b)  Each  utilization  review  agent  shall  assure  adherence to the
  requirements  stated  in  subsection  (a)  of  this   section   by   all
  contractors, subcontractors, subvendors, agents and employees affiliated
  by contract or otherwise with such utilization review agent.