4903-A – Utilization Review Determinations for Medically Fragile Children.
* § 4903-a. Utilization review determinations for medically fragile children. (a) Notwithstanding any inconsistent provision of the utilization review agent’s clinical standards, the utilization review agent shall administer and apply the clinical standards (and make determinations of medical necessity) regarding medically fragile children in accordance with the requirements of this section. To the extent any […]
4904 – Appeal of Adverse Determinations by Utilization Review Agents.
§ 4904. Appeal of adverse determinations by utilization review agents. (a) An insured, the insured’s designee and, in connection with retrospective adverse determinations, an insured’s health care provider, may appeal an adverse determination rendered by a utilization review agent. (a-1) An insured or the insured’s designee may appeal an out-of-network denial by a health care […]
4905 – Required and Prohibited Practices.
§ 4905. Required and prohibited practices. (a) Each utilization review agent shall have written procedures for assuring that patient-specific information obtained during the process of utilization review will be: (1) kept confidential in accordance with applicable state and federal laws; and (2) shared only with the insured, the insured’s designee, the insured’s health care provider […]
4906 – Waiver.
§ 4906. Waiver. (a) Any agreement which purports to waive, limit, disclaim, or in any way diminish the rights set forth in this article, except as provided pursuant to section four thousand nine hundred ten of this article shall be void as contrary to public policy. (b) Notwithstanding subsection (a) of this section, in lieu […]
4907 – Rights and Remedies.
§ 4907. Rights and remedies. The rights and remedies conferred in this article upon insureds and health care providers shall be cumulative and in addition to and not in lieu of any other rights or remedies available under law.
4900 – Definitions.
§ 4900. Definitions. For purposes of this article: (a) “Adverse determination” means a determination by a utilization review agent that an admission, extension of stay, or other health care service, upon review based on the information provided, is not medically necessary. * (b) “Clinical peer reviewer” means: (1) for purposes of title one of this […]
4901 – Reporting Requirements for Utilization Review Agents.
§ 4901. Reporting requirements for utilization review agents. (a) Every utilization review agent shall biennially report to the superintendent of financial services, in a statement subscribed and affirmed as true under the penalties of perjury, the information required pursuant to subsection (b) of this section. (b) Such report shall contain a description of the following: […]
4902 – Utilization Review Program Standards.
§ 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 […]
4903 – Utilization Review Determinations.
§ 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 […]