Section 4903. Utilization review determinations

(a) Utilization review
  shall be conducted by:
    (1) Administrative personnel trained in the principles and  procedures
  of   intake  screening  and  data  collection,  provided  however,  that
  administrative personnel  shall  only  perform  intake  screening,  data
  collection  and non-clinical review functions and shall be supervised by
  a licensed health care professional;
    (2) A health care professional who is  appropriately  trained  in  the
  principles,  procedures  and standards of such utilization review agent;
  provided, however, that a health care professional who is not a clinical
  peer reviewer may not render an adverse determination; and
    (3) A clinical peer reviewer where  the  review  involves  an  adverse
  determination.
    (b)  A  utilization  review  agent  shall  make  a  utilization review
  determination   involving   health   care   services    which    require
  pre-authorization  and  provide notice of a determination to the insured
  or  insured's  designee  and  the  insured's  health  care  provider  by
  telephone  and  in  writing within three business days of receipt of the
  necessary information.
    * (c) A utilization review agent shall make a determination  involving
  continued  or  extended health care services, or additional services for
  an insured undergoing a course of continued treatment  prescribed  by  a
  health  care  provider  and  provide notice of such determination to the
  insured or the insured's designee, which may be satisfied by  notice  to
  the  insured's  health care provider, by telephone and in writing within
  one business day of receipt of the necessary  information.  Notification
  of  continued  or extended services shall include the number of extended
  services approved, the new total of approved services, the date of onset
  of services and the next review date.
    * NB Effective until January 1, 2010
    * (c) A utilization review agent shall make a determination  involving
  continued  or  extended health care services, additional services for an
  insured undergoing a course  of  continued  treatment  prescribed  by  a
  health  care  provider,  or  home  health  care  services  following  an
  inpatient  hospital  admission,  and  shall  provide  notice   of   such
  determination  to  the  insured  or the insured's designee, which may be
  satisfied by notice to the insured's health care provider, by  telephone
  and  in  writing  within  one  business  day of receipt of the necessary
  information except, with respect to home health care services  following
  an  inpatient hospital admission, within seventy-two hours of receipt of
  the necessary information when the day subsequent to the  request  falls
  on  a weekend or holiday. Notification of continued or extended services
  shall include the number of extended services approved, the new total of
  approved services, the date of onset of services  and  the  next  review
  date.  Provided  that  a  request  for home health care services and all
  necessary information is submitted to the utilization review agent prior
  to discharge from an  inpatient  hospital  admission  pursuant  to  this
  subsection,  a  utilization review agent shall not deny, on the basis of
  medical necessity or lack of  prior  authorization,  coverage  for  home
  health  care  services  while  a determination by the utilization review
  agent is pending.
    * NB Effective January 1, 2010
    (d) A  utilization  review  agent  shall  make  a  utilization  review
  determination  involving  health care services which have been delivered
  within thirty days of receipt of the necessary information.
    (e) Notice of an adverse determination made by  a  utilization  review
  agent shall be in writing and must include:

    (1)   the   reasons  for  the  determination  including  the  clinical
  rationale, if any;
    (2)  instructions  on  how  to initiate standard appeals and expedited
  appeals pursuant to section four  thousand  nine  hundred  four  and  an
  external  appeal pursuant to section four thousand nine hundred fourteen
  of this article; and
    (3) 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.  Such  notice  shall  also  specify  what,  if  any,
  additional  necessary  information  must be provided to, or obtained by,
  the utilization review agent in  order  to  render  a  decision  on  the
  appeal.
    (f)  In  the  event that a utilization review agent renders an adverse
  determination  without  attempting  to  discuss  such  matter  with  the
  insured's  health  care provider who specifically recommended the health
  care service, procedure or treatment  under  review,  such  health  care
  provider  shall have the opportunity to request a reconsideration of the
  adverse determination. Except in cases of  retrospective  reviews,  such
  reconsideration  shall  occur  within one business day of receipt of the
  request and shall be conducted by the insured's health care provider and
  the clinical  peer  reviewer  making  the  initial  determination  or  a
  designated clinical peer reviewer if the original clinical peer reviewer
  cannot  be  available.  In  the  event that the adverse determination is
  upheld after reconsideration, the utilization review agent shall provide
  notice as required pursuant to subsection (e) of this  section.  Nothing
  in  this  section  shall  preclude the insured from initiating an appeal
  from an adverse determination.
    (g) Failure by the utilization review agent to  make  a  determination
  within the time periods prescribed in this section shall be deemed to be
  an  adverse  determination  subject  to  appeal pursuant to section four
  thousand nine hundred four of this title.