§ 4904. Appeal of adverse determinations by utilization review agents.\n(a) An insured, the insured's designee and, in connection with\nretrospective adverse determinations, an insured's health care provider,\nmay appeal an adverse determination rendered by a utilization review\nagent.\n (a-1) An insured or the insured's designee may appeal an\nout-of-network denial by a health care plan by submitting: (1) a written\nstatement from the insured's attending physician, who must be a\nlicensed, board certified or board eligible physician qualified to\npractice in the specialty area of practice appropriate to treat the\ninsured for the health services sought, that the requested\nout-of-network health service is materially different from the health\nservice the health care plan approved to treat the insured's health care\nneeds; and (2) two documents from the available medical and scientific\nevidence, that the out-of-network health service is likely to be more\nclinically beneficial to the insured than the alternate recommended\nin-network health service and for which the adverse risk of the\nrequested health service would likely not be substantially increased\nover the in-network health service.\n (a-2) An insured or the insured's designee may appeal an\nout-of-network referral denial by a health care plan by submitting a\nwritten statement from the insured's attending physician, who must be a\nlicensed, board certified or board eligible physician qualified to\npractice in the specialty area of practice appropriate to treat the\ninsured for the health service sought, provided that: (1) the in-network\nhealth care provider or providers recommended by the health care plan do\nnot have the appropriate training and experience to meet the particular\nhealth care needs of the insured for the health service; and (2)\nrecommends an out-of-network provider with the appropriate training and\nexperience to meet the particular health care needs of the insured, and\nwho is able to provide the requested health service.\n (b) A utilization review agent shall establish an expedited appeal\nprocess for appeal of an adverse determination involving (1) continued\nor extended health care services, procedures or treatments or additional\nservices for an insured undergoing a course of continued treatment\nprescribed by a health care provider or home health care services\nfollowing discharge from an inpatient hospital admission pursuant to\nsubsection (c) of section four thousand nine hundred three of this\ntitle; (2) an adverse determination in which the health care provider\nbelieves an immediate appeal is warranted except any retrospective\ndetermination; or (3) potential court-ordered mental health and/or\nsubstance use disorder services pursuant to paragraph two of subsection\n(b) of section four thousand nine hundred three of this title. Such\nprocess shall include mechanisms which facilitate resolution of the\nappeal including but not limited to the sharing of information from the\ninsured's health care provider and the utilization review agent by\ntelephonic means or by facsimile. The utilization review agent shall\nprovide reasonable access to its clinical peer reviewer within one\nbusiness day of receiving notice of the taking of an expedited appeal.\nExpedited appeals shall be determined within two business days of\nreceipt of necessary information to conduct such appeal except, with\nrespect to inpatient substance use disorder treatment provided pursuant\nto paragraph three of subsection (c) of section four thousand nine\nhundred three of this title, expedited appeals shall be determined\nwithin twenty-four hours of receipt of such appeal. Expedited appeals\nwhich do not result in a resolution satisfactory to the appealing party\nmay be further appealed through the standard appeal process, or through\nthe external appeal process pursuant to section four thousand nine\nhundred fourteen of this article as applicable. Provided that the\ninsu
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