Section 4912. Standards for certification

1. The commissioner shall develop
  an  application  for  certification.  At  a  minimum,  applicants  shall
  provide:
    (a) a description of the qualifications of the clinical peer reviewers
  retained to conduct external appeals of  final  adverse  determinations,
  including  such  reviewers'  current  and  past  employment  history and
  practice affiliations;
    (b) a description of the procedures employed to ensure  that  clinical
  peer reviewers conducting external appeals are:
    (i) appropriately licensed, registered or certified;
    (ii)  trained  in  the  principles,  procedures  and  standards of the
  external appeal agent; and
    (iii) knowledgeable about the health care service which is the subject
  of the final adverse determination under appeal;
    (c) a description of the methods of recruiting and selecting impartial
  clinical peer reviewers and matching such reviewers to specific cases;
    (d) the number of clinical peer reviewers  retained  by  the  external
  appeal agent, and a description of the areas of expertise available from
  such  reviewers  and  the types of cases such reviewers are qualified to
  review;
    (e) a description of the policies and procedures employed  to  protect
  the  confidentiality  of  individual  medical  and  treatment records in
  accordance with applicable state and federal laws;
    (f) a description of the quality assurance program established by  the
  external  appeal  agent  pursuant to paragraph (c) of subdivision two of
  this section;
    (g)  the  names  of  all  corporations  and  organizations  owned   or
  controlled  by  the external appeal agent or which owns or controls such
  agent, and the nature and extent of any such ownership or control;
    (h)  the  names  and  biographies  of  all  directors,  officers,  and
  executives of the external appeal agent;
    (i)  an  experimental  and  investigational  treatment  review plan to
  conduct appeals  pursuant  to  subparagraph  (B)  of  paragraph  (d)  of
  subdivision  two  of  section forty-nine hundred fourteen of this title;
  and
    (j) a description of the fees to be charged  by  agents  for  external
  appeals.
    2.  The  commissioner  shall, at a minimum, require an external appeal
  agent to:
    (a) appoint a medical director, who is a physician in possession of  a
  current  and  valid  non-restricted  license  to practice medicine. Such
  director shall be responsible for the supervision and oversight  of  the
  external appeal process;
    (b)  develop  written policies and procedures governing all aspects of
  the appeal process, including, at a minimum:
    (i) procedures to ensure that appeals are conducted  within  the  time
  frames  specified  in section forty-nine hundred fourteen of this title,
  and any required notices are provided in a timely manner;
    (ii) procedures to ensure the selection  of  qualified  and  impartial
  clinical  peer  reviewers.  Such  reviewers shall be qualified to render
  determinations relating to the health care service which is the  subject
  of the final adverse determination under appeal;
    (iii)   procedures  to  ensure  the  confidentiality  of  medical  and
  treatment records and review materials; and
    (iv) procedures to ensure adherence to the requirements of this  title
  by   any   contractor,   subcontractor,  subvendor,  agent  or  employee
  affiliated by contract or otherwise with such external appeal agent;

    (c) establish a quality assurance program. Such program shall  include
  written descriptions, to be provided to all individuals involved in such
  program,  of  the organizational arrangements and ongoing procedures for
  the identification, evaluation, resolution and  follow-up  of  potential
  and actual problems in external appeals performed by the external appeal
  agent  and  to  ensure  the maintenance of program standards pursuant to
  this section;
    (d) establish a toll-free telephone service to receive information  on
  a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant
  to  this  title. Such system shall be capable of accepting, recording or
  providing instruction to incoming  telephone  calls  during  other  than
  normal business hours, and;
    (e) develop procedures to ensure that:
    (i)  appropriate  personnel  are  reasonably  accessible not less than
  forty hours per week during normal business  hours  to  discuss  patient
  care and to allow response to telephone requests, and
    (ii)  response to accepted or recorded messages shall be made not less
  than one business day after the date on which the call was received.
    3. No entity shall be qualified to submit such request for application
  if it owns or controls, is owned or controlled by, or  exercises  common
  control with, any of the following:
    (a)  any  national,  state  or local illness, health benefit or public
  advocacy group;
    (b) any national, state or local society or association of  hospitals,
  physicians, or other providers of health care services; or
    (c) any national, state or local association of health care plans.
    4.  A  health  care  plan shall transmit, and an external appeal agent
  shall be authorized to receive and review,  an  enrollee's  medical  and
  treatment  records  in  order  to conduct an external appeal pursuant to
  this title.
    5. An  external  appeal  agent  shall  provide  ready  access  to  the
  commissioner  to  all  data,  records,  and  information  collected  and
  maintained concerning such agent's external appeal activities.
    6. An external appeal agent shall agree to  provide  the  commissioner
  such  data,  information,  and  reports  as  the commissioner determines
  necessary to evaluate the external appeal process  established  pursuant
  to this title.
    7.  The commissioner shall provide, upon the request of any interested
  person, a  copy  of  all  non-proprietary  information  filed  with  the
  commissioner by the external appeal agent. The commissioner may charge a
  reasonable  fee  to  the interested person for reproducing the requested
  information.