§ 4912. Standards for certification. (a) The superintendent shall\ndevelop an application for certification. At a minimum, applicants shall\nprovide:\n (1) a description of the qualifications of the clinical peer reviewers\nretained to conduct external appeals of final adverse determinations\nincluding such reviewers' current and past employment history and\npractice affiliations;\n (2) a description of the procedures employed to ensure that clinical\npeer reviewers conducting external appeals are:\n (i) appropriately licensed, registered or certified;\n (ii) trained in the principles, procedures and standards of the\nexternal appeal agent; and\n (iii) knowledgeable about the health care service which is the subject\nof the final adverse determination under appeal;\n (3) a description of the methods of recruiting and selecting impartial\nclinical peer reviewers and matching such reviewers to specific cases;\n (4) the number of clinical peer reviewers retained by the external\nappeal agent, and a description of the areas of expertise available from\nsuch reviewers and the types of cases such reviewers are qualified to\nreview;\n (5) a description of the policies and procedures employed to protect\nthe confidentiality of individual medical and treatment records in\naccordance with applicable state and federal laws;\n (6) a description of the quality assurance program established by the\nexternal appeal agent pursuant to paragraph three of subsection (b) of\nthis section;\n (7) the names of all corporations and organizations owned or\ncontrolled by the external appeal agent, or which owns or controls such\nagent, and the nature and extent of any such ownership or control;\n (8) the names and biographies of all directors, officers, and\nexecutives of the external appeal agent;\n (9) an experimental and investigational treatment review plan to\nconduct appeals pursuant to subparagraph (B) of paragraph four of\nsubsection (b) of section four thousand nine hundred fourteen of this\ntitle; and\n (10) a description of the fees to be charged by agents for external\nappeals.\n (b) The superintendent shall, at a minimum, require an external appeal\nagent to:\n (1) appoint a medical director, who is a physician in possession of a\ncurrent and valid non-restricted license to practice medicine. Such\ndirector shall be responsible for the supervision and oversight of the\nexternal appeal process;\n (2) develop written policies and procedures governing all aspects of\nthe appeal process, including, at a minimum:\n (i) procedures to ensure that appeals are conducted within the time\nframes specified in section four thousand nine hundred fourteen of this\ntitle, and any required notices are provided in a timely manner;\n (ii) procedures to ensure the selection of qualified and impartial\nclinical peer reviewers. Such reviewers shall be qualified to render and\nimpartial determinations relating to the health care service which is\nthe subject of the final adverse determination under appeal;\n (iii) procedures to ensure the confidentiality of medical and\ntreatment records and review materials; and\n (iv) procedures to ensure adherence to the requirements of this title\nby any contractor, subcontractor, subvendor, agent or employee\naffiliated by contract or otherwise with such external appeal agent;\n (3) establish a quality assurance program. Such program shall include\nwritten descriptions, to be provided to all individuals involved in such\nprogram, of the organizational arrangements and ongoing procedures for\nthe identification, evaluation, resolution and follow-up of potential\nand actual problems in external appeals performed by the external appeal\nagent and to ensure the maintenance of program standards pursuant to\nthis section;\n (4) establish a toll-free telephone service to receive information on\na 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant\nto this title. Such system shall be capabl
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