§ 4903. Utilization review determinations. (a) Utilization review\nshall be conducted by:\n (1) Administrative personnel trained in the principles and procedures\nof intake screening and data collection, provided however, that\nadministrative personnel shall only perform intake screening, data\ncollection and non-clinical review functions and shall be supervised by\na licensed health care professional;\n (2) A health care professional who is appropriately trained in the\nprinciples, procedures and standards of such utilization review agent;\nprovided, however, that a health care professional who is not a clinical\npeer reviewer may not render an adverse determination; and\n (3) A clinical peer reviewer where the review involves an adverse\ndetermination.\n (b) (1) A utilization review agent shall make a utilization review\ndetermination involving health care services which require\npre-authorization and provide notice of a determination to the insured\nor insured's designee and the insured's health care provider by\ntelephone and in writing within three business days of receipt of the\nnecessary information, or for inpatient rehabilitation services\nfollowing an inpatient hospital admission provided by a hospital or\nskilled nursing facility, within one business day of receipt of the\nnecessary information. The notification shall identify: (i) whether the\nservices are considered in-network or out-of-network; (ii) whether the\ninsured will be held harmless for the services and not be responsible\nfor any payment, other than any applicable co-payment, co-insurance or\ndeductible; (iii) as applicable, the dollar amount the health care plan\nwill pay if the service is out-of-network; and (iv) as applicable,\ninformation explaining how an insured may determine the anticipated\nout-of-pocket cost for out-of-network health care services in a\ngeographical area or zip code based upon the difference between what the\nhealth care plan will reimburse for out-of-network health care services\nand the usual and customary cost for out-of-network health care\nservices.\n (2) With regard to individual or group contracts authorized pursuant\nto article thirty-two, forty-three or forty-seven of this chapter or\narticle forty-four of the public health law, for utilization and review\ndeterminations involving proposed mental health and/or substance use\ndisorder services where the insured or the insured's designee has, in a\nformat prescribed by the superintendent, certified in the request that\nthe proposed services are for an individual who will be appearing, or\nhas appeared, before a court of competent jurisdiction and may be\nsubject to a court order requiring such services, the utilization review\nagent shall make a determination and provide notice of such\ndetermination to the insured or the insured's designee by telephone\nwithin seventy-two hours of receipt of the request. Written notice of\nthe determination to the insured or insured's designee shall follow\nwithin three business days. Where feasible, such telephonic and written\nnotice shall also be provided to the court.\n (c) (1) A utilization review agent shall make a determination\ninvolving continued or extended health care services, additional\nservices for an insured undergoing a course of continued treatment\nprescribed by a health care provider, or requests for inpatient\nsubstance use disorder treatment, or home health care services following\nan inpatient hospital admission, and shall provide notice of such\ndetermination to the insured or the insured's designee, which may be\nsatisfied by notice to the insured's health care provider, by telephone\nand in writing within one business day of receipt of the necessary\ninformation except, with respect to home health care services following\nan inpatient hospital admission, within seventy-two hours of receipt of\nthe necessary information when the day subsequent to the request falls\non a weekend or holiday and except, wit
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