§ 4914. Procedures for external appeals of adverse determinations. 1.\nThe commissioner shall establish procedures by regulation to randomly\nassign an external appeal agent to conduct an external appeal, provided\nthat the commissioner may establish a maximum fee which may be charged\nfor any such external appeal, or the commissioner may exclude from such\nrandom assignment any external appeal agent which charges a fee which\nshe deems to be unreasonable.\n 2. (a) The enrollee shall have four months to initiate an external\nappeal after the enrollee receives notice from the health care plan, or\nsuch plan's utilization review agent if applicable, of a final adverse\ndetermination or denial or after both the plan and the enrollee have\njointly agreed to waive any internal appeal, or after the enrollee is\ndeemed to have exhausted or is not required to complete any internal\nappeal pursuant to section 2719 of the Public Health Service Act, 42\nU.S.C. § 300gg-19. Where applicable, the enrollee's health care provider\nshall have sixty days to initiate an external appeal after the enrollee\nor the enrollee's health care provider, as applicable, receives notice\nfrom the health care plan, or such plan's utilization review agent if\napplicable, of a final adverse determination or denial or after both the\nplan and the enrollee have jointly agreed to waive any internal appeal.\nSuch request shall be in writing in accordance with the instructions and\nin such form prescribed by subdivision five of this section. The\nenrollee, and the enrollee's health care provider where applicable,\nshall have the opportunity to submit additional documentation with\nrespect to such appeal to the external appeal agent within the\napplicable time period above; provided however that when such\ndocumentation represents a material change from the documentation upon\nwhich the utilization review agent based its adverse determination or\nupon which the health plan based its denial, the health plan shall have\nthree business days to consider such documentation and amend or confirm\nsuch adverse determination.\n (b) The external appeal agent shall make a determination with respect\nto the appeal within thirty days of the receipt of the request therefor,\nsubmitted in accordance with the commissioner's instructions. The\nexternal appeal agent shall have the opportunity to request additional\ninformation from the enrollee, the enrollee's health care provider and\nthe enrollee's health care plan within such thirty-day period, in which\ncase the agent shall have up to five additional business days if\nnecessary to make such determination. The external appeal agent shall\nnotify the enrollee, the enrollee's health care provider where\nappropriate, and the health care plan, in writing, of the appeal\ndetermination within two business days of the rendering of such\ndetermination.\n (c) Notwithstanding the provisions of paragraphs (a) and (b) of this\nsubdivision, if the enrollee's attending physician states that a delay\nin providing the health care service would pose an imminent or serious\nthreat to the health of the enrollee, or if the enrollee is entitled to\nan expedited external appeal pursuant to section 2719 of the federal\nPublic Health Service Act, 42 U.S.C. § 300gg-19, the external appeal\nshall be completed within no more than seventy-two hours of the request\ntherefor and the external appeal agent shall make every reasonable\nattempt to immediately notify the enrollee, the enrollee's health care\nprovider where appropriate, and the health plan of its determination by\ntelephone or facsimile, followed immediately by written notification of\nsuch determination.\n (d) (A) For external appeals requested pursuant to paragraph (a) of\nsubdivision two of section forty-nine hundred ten of this title, the\nexternal appeal agent shall review the utilization review agent's final\nadverse determination and, in accordance with the provisions of this\ntitle, shal
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