§ 4902. Utilization review program standards. (a) Each utilization\nreview agent shall adhere to utilization review program standards\nconsistent with the provisions of this title which shall, at a minimum,\ninclude:\n (1) Appointment of a medical director, who is a licensed physician;\nprovided, however, that the utilization review agent may appoint a\nclinical director when the utilization review performed is for a\ndiscrete category of health care service and provided further that the\nclinical director is a licensed health care professional who typically\nmanages the category of service. Responsibilities of the medical\ndirector, or, where appropriate, the clinical director, shall include,\nbut not be limited to, the supervision and oversight of the utilization\nreview process;\n (2) Development of written policies and procedures that govern all\naspects of the utilization review process and a requirement that a\nutilization review agent shall maintain and make available to insureds\nand health care providers a written description of such procedures\nincluding procedures to appeal an adverse determination together with a\ndescription, jointly promulgated by the superintendent and the\ncommissioner of health as required pursuant to subsection (e) of section\nfour thousand nine hundred fourteen of this article, of the external\nappeal process established pursuant to title two of this article and the\ntime frames for such appeals;\n (3) Utilization of written clinical review criteria developed pursuant\nto a utilization review plan;\n (4) Establishment of a process for rendering utilization review\ndeterminations which shall, at a minimum, include: written procedures to\nassure that utilization reviews and determinations are conducted within\nthe timeframes established herein; procedures to notify an insured, an\ninsured's designee and/or an insured's health care provider of adverse\ndeterminations; and procedures for appeal of adverse determinations\nincluding the establishment of an expedited appeals process for denials\nof continued inpatient care or where there is imminent or serious threat\nto the health of the insured;\n (5) (i) Establishment of a written procedure to assure that the notice\nof an adverse determination includes:\n (A) the reasons for the determination including the clinical\nrationale, if any;\n (B) instructions on how to initiate standard and expedited appeals\npursuant to section four thousand nine hundred four of this article and\nan external appeal pursuant to section four thousand nine hundred\nfourteen of this article; (C) notice of the availability, upon request\nof the insured or the insured's designee, of the clinical review\ncriteria relied upon to make such determination;\n (D) what, if any, additional necessary information must be provided\nto, or obtained by, the utilization review agent in order to render a\ndecision on appeal; and\n (E) for an adverse determination related to a step therapy protocol\noverride determination, information that includes the clinical review\ncriteria relied upon to make such determination and any applicable\nalternative prescription drugs subject to the step therapy protocol of\nthe utilization review agent.\n (ii) A utilization review agent may provide a notice of an adverse\ndetermination related to a step therapy protocol override determination\nelectronically pursuant to subsection (i) of section four thousand nine\nhundred three of this title, including by electronic mail or through the\nhealth care plan's member portal and provider portal. An electronic\nnotice of such an adverse determination may meet the requirements of\nclause (E) of subparagraph (i) of this paragraph by linking to\ninformation posted on the website of the health care plan;\n (6) Establishment of a requirement that appropriate personnel of the\nutilization review agent are reasonably accessible by toll-free\ntelephone:\n (i) not less than forty hours per week during normal
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