§ 4909. Site of service clinical review. 1. For purposes of this\nsection:\n (a) "Free-standing ambulatory surgical center" shall mean a diagnostic\nand treatment center authorized pursuant to article twenty-eight of this\nchapter and operated independently from a hospital.\n (b) "Health care plan" shall mean an insurer, a corporation organized\npursuant to article forty-three of the insurance law, a health\nmaintenance organization certified pursuant to article forty-four of\nthis chapter, a municipal cooperative health benefit plan certified\npursuant to article forty-seven of the insurance law, and a student\nhealth plan established or maintained pursuant to section one thousand\none hundred twenty-four of the insurance law, that issues a health\ninsurance policy or contract or that arranges for care and services for\nmembers under a contract with the department with a network of health\ncare providers and utilizes site of service clinical review to determine\ncoverage for services delivered by network participating providers.\n (c) "Hospital-based outpatient clinic" shall mean a clinic authorized\npursuant to article twenty-eight of this chapter and listed on a\nhospital's operating certificate.\n (d) "Site of service clinical review" shall mean clinical criteria\napplied by a health care plan for the purpose of determining whether\nnon-urgent outpatient medical procedures and surgeries will be covered\nfor a given insured or enrollee when rendered by a network participating\nprovider at a hospital-based outpatient clinic rather than a\nfree-standing ambulatory surgical center.\n 2. Site of service clinical review shall be deemed utilization review\nin accordance with and subject to the requirements and protections of\nthis article and article forty-nine of the insurance law, including the\nright to internal and external appeal of denials related to site of\nservice clinical review.\n 3. Site of service clinical review shall consider the insured's health\nand safety, choice of health care provider, and timely access to care\nand shall not be based solely on cost.\n 4. A health care plan that utilizes site of service clinical review\nthat is intended to direct insureds and enrollees to free-standing\nambulatory surgical centers shall be able to demonstrate to the\ndepartment that it has an adequate network of free-standing ambulatory\nsurgical center providers to meet the health needs of insureds and\nenrollees and to provide an appropriate choice of providers sufficient\nto render the services covered under the policy or contract. Such\nnetwork shall be in compliance with network adequacy standards\nestablished by the commissioner and article forty-four of this chapter.\n 5. Except as provided in subdivision seven of this section, starting\nJanuary first, two thousand twenty-four, a health care plan that\nutilizes a site of service clinical review shall deliver a notice\ndisclosing and clearly explaining the site of service clinical review\nto:\n (a) policyholders, contract holders, insureds, and enrollees and\nprospective policyholders, contract holders, insureds, and enrollees at\nthe time of plan and policy or contract selection and at least ninety\ndays prior to the implementation of new site of service clinical review\nor modification of existing site of service clinical review. Such notice\nshall include the specific services under the site of service review\npolicy, a statement that site of service clinical review may limit the\nsettings in which services covered under the policy or contract may be\nprovided and render a network participating provider unable to perform a\nservice; shall disclose to insureds or enrollees any quality or cost\ndifferential, including differences in out-of-pocket costs, between the\nhospital-based outpatient clinic and the free-standing ambulatory\nsurgical center when services at a hospital-based outpatient clinic are\nrequested; and shall set forth any rights the insured or e
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