§ 4902. Utilization review program standards. 1. 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 (a) 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 (b) 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 enrollees\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 commissioner and the\nsuperintendent of financial services as required pursuant to subdivision\nfive of section forty-nine hundred fourteen of this article, of the\nexternal appeal process established pursuant to title two of this\narticle and the time frames for such appeals;\n (c) Utilization of written clinical review criteria developed pursuant\nto a utilization review plan;\n (d) 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 enrollee, an\nenrollee's designee and/or an enrollee'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 enrollee;\n (e) (i) Establishment of a written procedure to assure that the notice\nof an adverse determination includes: (1) the reasons for the\ndetermination including the clinical rationale, if any; (2) instructions\non how to initiate standard and expedited appeals pursuant to section\nforty-nine hundred four and an external appeal pursuant to section\nforty-nine hundred fourteen of this article; (3) notice of the\navailability, upon request of the enrollee or the enrollee's designee,\nof the clinical review criteria relied upon to make such determination;\n(4) what, if any, additional necessary information must be provided to,\nor obtained by, the utilization review agent in order to render a\ndecision on an appeal; and (5) for an adverse determination related to a\nstep therapy protocol override determination, information that includes\nthe clinical review criteria relied upon to make such determination and\nany applicable alternative prescription drugs subject to the step\ntherapy protocol of the utilization review agent.\n (ii) A utilization review agent may provide notice of an adverse\ndetermination related to a step therapy protocol override determination\nelectronically pursuant to subdivision nine of section forty-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 five of subparagraph (i) of this paragraph by linking to\ninformation posted on the website of the health care plan;\n (f) 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 business hours to\ndiscuss patient
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