§ 4903. Utilization review determinations. 1. Utilization review shall\nbe conducted by:\n (a) 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 (b) 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 (c) A clinical peer reviewer where the review involves an adverse\ndetermination.\n 2. (a) 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 enrollee\nor enrollee's designee and the enrollee'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) and whether\nthe enrollee will be held harmless for the services and not be\nresponsible for any payment, other than any applicable co-payment or\nco-insurance; (iii) as applicable, the dollar amount the health care\nplan will pay if the service is out-of-network; and (iv) as applicable,\ninformation explaining how an enrollee 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 (b) With regard to individual or group contracts authorized pursuant\nto article forty-four of this chapter, for utilization review\ndeterminations involving proposed mental health and/or substance use\ndisorder services where the enrollee or the enrollee's designee has, in\na format prescribed by the superintendent of financial services,\ncertified in the request that the proposed services are for an\nindividual who will be appearing, or has appeared, before a court of\ncompetent jurisdiction and may be subject to a court order requiring\nsuch services, the utilization review agent shall make a determination\nand provide notice of such determination to the enrollee or the\nenrollee's designee by telephone within seventy-two hours of receipt of\nthe request. Written notice of the determination to the enrollee or\nenrollee's designee shall follow within three business days. Where\nfeasible, such telephonic and written notice shall also be provided to\nthe court.\n 3. (a) A utilization review agent shall make a determination involving\ncontinued or extended health care services, additional services for an\nenrollee undergoing a course of continued treatment prescribed by a\nhealth care provider, or requests for inpatient substance use disorder\ntreatment, or home health care services following an inpatient hospital\nadmission, and shall provide notice of such determination to the\nenrollee or the enrollee's designee, which may be satisfied by notice to\nthe enrollee's health care provider, by telephone and in writing within\none business day of receipt of the necessary information except, with\nrespect to home health care services following an inpatient hospital\nadmission, within seventy-two hours of receipt of the necessary\ninformation when the day subsequent to the request falls on a weekend or\nholiday and except, with respect to inpatient substance use disorder\ntreatm
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