§ 4910. Right to external appeal established. (a) There is hereby established an insured’s right to an external appeal of a final adverse determination by a health plan. (b) An insured, the insured’s designee and, in connection with concurrent and retrospective adverse determinations, an insured’s health care provider, shall have the right to request an […]
§ 4911. Powers of the superintendent. (a) The superintendent shall have the power to grant and revoke certifications of external appeal agents to conduct external appeals requested pursuant to paragraph one or two of subsection (b) of section four thousand nine hundred ten of this title or pursuant to both such paragraphs. (b) If, after […]
§ 4912. Standards for certification. (a) The superintendent shall develop an application for certification. At a minimum, applicants shall provide: (1) 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; (2) a description of […]
§ 4913. Conflict of interest. (a) No external appeal agent or officer, director, or management employee thereof; or clinical peer reviewer employed or engaged thereby to conduct any external appeal pursuant to this title, shall have any material professional affiliation, material familial affiliation, material financial affiliation, or other affiliation prescribed pursuant to regulation, with any […]
§ 4914. Procedures for external appeals of adverse determinations. (a) The superintendent shall establish procedures by regulation to randomly assign an external appeal agent to conduct an external appeal, provided that the superintendent may establish a maximum fee which may be charged for any such external appeal, or the superintendent may exclude from such random […]
§ 4915. Prohibited practices. An external appeal agent shall not, with respect to external appeal activities, permit or provide compensation or anything of value to its employees, agents, or contractors based on: (a) either a percentage of the amount by which a claim is reduced for payment or the number of claims or the cost […]
§ 4916. Oversight and surveillance of the external appeal process. (a) The superintendent shall have the power to: (1) review the activities of the health care plans and external appeal agents pursuant to this title, including the extent to which such plans and agents adhere to the standards and time frames required pursuant to this […]
§ 4917. Hold harmless. A health care provider requesting an external appeal of a concurrent adverse determination, including when the health care provider requests an external appeal as the insured’s designee, shall not pursue reimbursement from the insured for services determined not medically necessary by the external appeal agent, except to collect a copayment, coinsurance […]
