Section 4902. Utilization review program standards

1. Each utilization
  review agent  shall  adhere  to  utilization  review  program  standards
  consistent  with the provisions of this title which shall, at a minimum,
  include:
    (a) 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;
    (b) 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  enrollees
  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   commissioner  and  the
  superintendent of insurance as required pursuant to subdivision five  of
  section  forty-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;
    (c) Utilization of written clinical review criteria developed pursuant
  to a utilization review plan;
    (d) 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 enrollee,  an
  enrollee's designee and/or an enrollee'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 enrollee;
    (e)  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  forty-nine  hundred  four  and an external appeal
  pursuant to section forty-nine hundred fourteen of this article; and
    (iii) notice of the availability, upon request of the enrollee or  the
  enrollee's designee, of the clinical review criteria relied upon to make
  such determination;
    (f)  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
  subdivision three of section forty-nine hundred three of this  title  or

  an  expedited  appeal  filed  pursuant  to  subdivision  two  of section
  forty-nine hundred four of this title, on  a  twenty-four  hour  a  day,
  seven day a week basis;
    (g)  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;
    (h) Establishment of a requirement that emergency services rendered to
  an  enrollee  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.
    2. Each  utilization  review  agent  shall  assure  adherence  to  the
  requirements   stated   in  subdivision  one  of  this  section  by  all
  contractors, subcontractors, subvendors, agents and employees affiliated
  by contract or otherwise with such utilization review agent.