§ 4408. Disclosure of information. 1. Each subscriber, and upon\nrequest each prospective subscriber prior to enrollment, shall be\nsupplied with written disclosure information which may be incorporated\ninto the member handbook or the subscriber contract or certificate\ncontaining at least the information set forth below. In the event of any\ninconsistency between any separate written disclosure statement and the\nsubscriber contract or certificate, the terms of the subscriber contract\nor certificate shall be controlling. The information to be disclosed\nshall include at least the following:\n (a) a description of coverage provisions; health care benefits;\nbenefit maximums, including benefit limitations; and exclusions of\ncoverage, including the definition of medical necessity used in\ndetermining whether benefits will be covered;\n (b) a description of all prior authorization or other requirements for\ntreatments and services;\n (c) a description of utilization review policies and procedures used\nby the health maintenance organization, including:\n (i) the circumstances under which utilization review will be\nundertaken;\n (ii) the toll-free telephone number of the utilization review agent;\n (iii) the timeframes under which utilization review decisions must be\nmade for prospective, retrospective and concurrent decisions;\n (iv) the right to reconsideration;\n (v) the right to an appeal, including the expedited and standard\nappeals processes and the time frames for such appeals;\n (vi) the right to designate a representative;\n (vii) a notice that all denials of claims will be made by qualified\nclinical personnel and that all notices of denials will include\ninformation about the basis of the decision;\n (viii) a notice of the right to an external appeal together with a\ndescription, jointly promulgated by the commissioner and the\nsuperintendent of financial services as required pursuant to subdivision\nfive of section forty-nine hundred fourteen of this chapter, of the\nexternal appeal process established pursuant to title two of article\nforty-nine of this chapter and the timeframes for such appeals; and\n (ix) further appeal rights, if any;\n (d) a description prepared annually of the types of methodologies the\nhealth maintenance organization uses to reimburse providers specifying\nthe type of methodology that is used to reimburse particular types of\nproviders or reimburse for the provision of particular types of\nservices; provided, however, that nothing in this paragraph should be\nconstrued to require disclosure of individual contracts or the specific\ndetails of any financial arrangement between a health maintenance\norganization and a health care provider;\n (e) an explanation of a subscriber's financial responsibility for\npayment of premiums, coinsurance, co-payments, deductibles and any other\ncharges, annual limits on a subscriber's financial responsibility, caps\non payments for covered services and financial responsibility for\nnon-covered health care procedures, treatments or services provided\nwithin the health maintenance organization;\n (f) an explanation of a subscriber's financial responsibility for\npayment when services are provided by a health care provider who is not\npart of the health maintenance organization or by any provider without\nrequired authorization or when a procedure, treatment or service is not\na covered health care benefit;\n (g) a description of the grievance procedures to be used to resolve\ndisputes between a health maintenance organization and an enrollee,\nincluding: the right to file a grievance regarding any dispute between\nan enrollee and a health maintenance organization; the right to file a\ngrievance orally when the dispute is about referrals or covered\nbenefits; the toll-free telephone number which enrollees may use to file\nan oral grievance; the timeframes and circumstances for expedited and\nstandard grievances; the right to appeal a grievanc
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