§ 4904. Appeal of adverse determinations by utilization review agents.\n1. An enrollee, the enrollee's designee and, in connection with\nretrospective adverse determinations, an enrollee's health care\nprovider, may appeal an adverse determination rendered by a utilization\nreview agent.\n 1-a. An enrollee or the enrollee's designee may appeal an\nout-of-network denial by a health care plan by submitting: (a) a written\nstatement from the enrollee'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\nenrollee for the health service 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 (b) 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 enrollee 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 1-b. An enrollee or the enrollee's designee may appeal a denial of an\nout-of-network referral by a health care plan by submitting a written\nstatement from the enrollee'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\nenrollee for the health service sought, provided that: (a) the\nin-network health care provider or providers recommended by the health\ncare plan do not have the appropriate training and experience to meet\nthe particular health care needs of the enrollee for the health service;\nand (b) recommends an out-of-network provider with the appropriate\ntraining and experience to meet the particular health care needs of the\nenrollee, and who is able to provide the requested health service.\n 2. A utilization review agent shall establish an expedited appeal\nprocess for appeal of an adverse determination involving:\n (a) continued or extended health care services, procedures or\ntreatments or additional services for an enrollee undergoing a course of\ncontinued treatment prescribed by a health care provider home health\ncare services following discharge from an inpatient hospital admission\npursuant to subdivision three of section forty-nine hundred three of\nthis title; or\n (b) an adverse determination in which the health care provider\nbelieves an immediate appeal is warranted except any retrospective\ndetermination; or\n (c) potential court-ordered mental health and/or substance use\ndisorder services pursuant to paragraph (b) of subdivision two of\nsection forty-nine hundred three of this title. Such process shall\ninclude mechanisms which facilitate resolution of the appeal including\nbut not limited to the sharing of information from the enrollee's health\ncare provider and the utilization review agent by telephonic means or by\nfacsimile. The utilization review agent shall provide reasonable access\nto its clinical peer reviewer within one business day of receiving\nnotice of the taking of an expedited appeal. Expedited appeals shall be\ndetermined within two business days of receipt of necessary information\nto conduct such appeal except, with respect to inpatient substance use\ndisorder treatment provided pursuant to paragraph (c) of subdivision\nthree of section forty-nine hundred three of this title, expedited\nappeals shall be determined within twenty-four hours of receipt of such\nappeal. Expedited appeals which do not result in a resolution\nsatisfactory to the appealing party may be further appealed through the\nstandard appeal process, or through the external appeal process pursuant\nto section forty-nine hundred fourteen of this article as applicable.\nProvided that the enrollee
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