§ 4900. Definitions. For purposes of this article:\n (a) "Adverse determination" means a determination by a utilization\nreview agent that an admission, extension of stay, or other health care\nservice, upon review based on the information provided, is not medically\nnecessary.\n (b) "Clinical peer reviewer" means:\n (1) for purposes of section four thousand nine hundred three of this\narticle:\n (A) a physician who possesses a current and valid non-restricted\nlicense to practice medicine; or\n (B) a health care professional other than a licensed physician who:\n (i) where applicable, possesses a current and valid non-restricted\nlicense, certificate or registration or, where no provision for a\nlicense, certificate or registration exists, is credentialed by the\nnational accrediting body appropriate to the profession; and\n (ii) is in the same profession and same or similar specialty as the\nhealth care provider who typically manages the medical condition or\ndisease or provides the health care service or treatment under review;\nor\n (C) for purposes of a determination involving substance use disorder\ntreatment:\n (i) a physician who possesses a current and valid non-restricted\nlicense to practice medicine and who specializes in behavioral health\nand has experience in the delivery of substance use disorder courses of\ntreatment; or\n (ii) a health care professional other than a licensed physician who\nspecializes in behavioral health and has experience in the delivery of\nsubstance use disorder courses of treatment and, where applicable,\npossesses a current and valid non-restricted license, certificate or\nregistration or, where no provision for a license, certificate or\nregistration exists, is credentialed by the national accrediting body\nappropriate to the profession; or\n (D) for purposes of a determination involving treatment for a mental\nhealth condition:\n (i) a physician who possesses a current and valid non-restricted\nlicense to practice medicine and who specializes in behavioral health\nand has experience in the delivery of mental health courses of\ntreatment; or\n (ii) a health care professional other than a licensed physician who\nspecializes in behavioral health and has experience in the delivery of\nmental health courses of treatment and, where applicable, possesses a\ncurrent and valid non-restricted license, certificate, or registration\nor, where no provision for a license, certificate or registration\nexists, is credentialed by the national accrediting body appropriate to\nthe profession; and\n (2) for purposes of section four thousand nine hundred four and title\ntwo of this article:\n (A) a physician who:\n (i) possesses a current and valid non-restricted license to practice\nmedicine;\n (ii) where applicable, is board certified or board eligible in the\nsame or similar specialty as the health care provider who typically\nmanages the medical condition or disease or provides the health care\nservice or treatment under appeal;\n (iii) for purposes of title two of this article, has been practicing\nin such area of specialty for a period of at least five years;\n (iv) for purposes of a determination involving substance use disorder\ntreatment, possesses a current and valid non-restricted license to\npractice medicine and who specializes in behavioral health and has\nexperience in the delivery of substance use disorder courses of\ntreatment;\n (v) for purposes of a determination involving treatment for a mental\nhealth condition, possesses a current and valid non-restricted license\nto practice medicine and who specializes in behavioral health and has\nexperience in the delivery of mental health courses of treatment; and\n (vi) is knowledgeable about the health care service or treatment under\nappeal; or\n (B) a health care professional other than a licensed physician who:\n (i) where applicable, possesses a current and valid non-restricted\nlicense, certificate or registration;\
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