N.Y. Comp. Codes R. & Regs. Tit. 11 § 410.10 - Responsibilities of certified external appeal agents
(a) Within 24 hours of receiving assignment
from the superintendent of a request for external appeal, certified external
appeal agents shall send notification of such assignment to the insured
requesting an external appeal or on whose behalf an external appeal is
requested, the insured's health care plan, the attending physician , as
applicable, and, in the case of a provider initiated appeal of a retrospective
adverse determination, the insured's health care provider. The certified
external appeal agent shall include in such notification:
(1) a request for any additional
documentation that may be available to support the appeal;
(2) the address to which any required or
additional documentation should be sent;
(3) whether the appeal is a standard or
expedited appeal; and
(4) for
purposes of notifying the insured's health care plan, as applicable, copies of
the documents relied upon by the insured's attending physician to establish
medical and scientific evidence that the recommended health care service is
likely to be more beneficial to the insured than any covered standard health
care service or procedure.
(b) Certified external appeal agents shall
make a final determination on nonexpedited external appeals within 30 days of
receiving the request for external appeal from the superintendent, provided
that, in the event that the certified external appeal agent requests additional
documentation from the insured, the insured's health care plan, the insured's
attending physician or health care provider, other than the documentation
requested pursuant to subdivision (a) of this section, the certified external
appeal agent shall have an additional five business days from receipt of the
request for external appeal from the superintendent within which to make a
final determination. Certified external appeal agents shall notify the
superintendent if additional documentation has been requested.
(c) Certified external appeal agents shall
make a final determination on expedited external appeals within three days of
receiving the request for external appeal from the superintendent.
(d) In addition to the requirements in
section
4914(b)(4) of the
Insurance Law and section 4914.2(d) of the Public Health Law the external
appeal agent shall consider any documentation submitted by the insured or the
insured's designee, the insured's attending physician , the insured's health
care plan or the insured's health care provider that is pertinent to the
external appeal under review provided that such documentation is submitted by
the earlier of:
(1) within 45 days from when
the insured or, in the case of a provider initiated retrospective appeal, the
insured's health care provider received notice that the health care plan made a
final adverse determination or within 45 days of the date from when the insured
received a letter from the health care plan affirming that both the insured and
the insured's health care plan jointly agreed to waive the internal appeal
process; or
(2) prior to the
external review agent's final determination on the appeal.
A certified external appeal agent may not reconsider an appeal for which a final determination has been made based upon receipt of additional information subsequent to such final determination.
(e) The certified
external appeal agent shall forward to the insured's health care plan any
documentation received by the certified external appeal agent that is pertinent
to an appeal that has been referred to the agent by the superintendent. Any
such documentation that, in the opinion of the certified external appeal agent,
constitutes a material change from the documentation upon which the utilization
review agent based its adverse determination or upon which the health care plan
based its denial shall be forwarded immediately, but no later than 24 hours
after receipt of such documentation, to the insured's health care plan, with
notification that such documentation represents a material change, for
consideration pursuant to section
4914(b)(1) of the
Insurance Law and section 4914.2(a) of the Public Health Law. In the event of
receipt of such material documentation, for other than expedited appeals, the
certified external appeal agent shall not issue a determination for up to three
business days or until the health care plan has considered such documentation
and amended, reversed or confirmed the adverse determination, whichever is
earlier.
(f) For each external
appeal determination made by a certified external appeal agent, the medical
director of the certified external appeal agent shall certify that:
(1) the certified external appeal agent and
each clinical peer reviewer assigned to review the external appeal followed
appropriate procedures as defined in section
4914 of the Insurance Law and Public Health
Law, this section, and the certified external appeal agent's application and,
as applicable, conditions for certification;
(2) all clinical peer reviewers met the
criteria for conducting the external review pursuant to section
4900(b) of the Insurance
Law and section
4900(2) of the Public
Health Law; and
(3) for each
clinical peer reviewer assigned to review the external appeal, a duly signed
and notarized attestation which affirms, under penalty of perjury, that no
prohibited material affiliation exists with respect to such clinical peer
reviewer's participation in the review of the external appeal pursuant to
section
410.6(e)-(f) and
(h) of this Part, is on file with the
certified external appeal agent. Such attestation shall be in such form as
prescribed by the superintendent and commissioner .
(g) Certified external appeal agents shall
forward copies of appeal determination notification letters sent to health care
plans and insureds pursuant to section
4914(b)(2) and (3) of the
Insurance Law and section 4914.2(b) and (c) of the Public Health Law to the
insured's health care provider, if applicable, and to the superintendent and
commissioner . Such notification letters shall include:
(1) a clear statement of the health care
plan's responsibility in regard to provision of the contested health care
service to the insured;
(2) a
statement attesting that no prohibited material affiliation existed with
respect to the clinical peer reviewers; and
(3) with respect to a medical necessity
appeal determination, the reasons for the determination, which shall include a
discussion of the health care plan's clinical standards, the information
provided concerning the patient, the attending physician 's recommendation, and
applicable and generally accepted practice guidelines developed by the Federal
government, national or professional medical societies, boards and associations
which were used in making the determination; or
(4) with respect to an experimental or
investigational treatment or service appeal determination, a statement as to
whether the proposed health service or treatment is likely to be more
beneficial than any standard treatment or treatments for the insured's
life-threatening or disabling condition or disease; or
(5) with respect to a clinical trial appeal
determination, a statement as to whether the clinical trial is likely to
benefit the insured in the treatment of the insured's condition or
disease.
(h) Certified
external appeal agents shall enclose a request for payment with the copy of the
appeal notification letter sent to the health care plan.
(i) Certified external appeal agents shall
not be relieved of responsibility for making a determination with respect to an
assigned external appeal on the basis that the insured no longer has coverage
with the health care plan that denied the health care service(s) that is the
subject of the appeal. However, a health care plan will not be required to pay
the patient costs of any health service(s) or procedure(s) that is the subject
of an external appeal for insureds who no longer have coverage with such health
care plan unless, and to the extent that the health care service(s) was
provided while the insured had coverage with the health care plan.
(j) In addition to the information required
by section
4916(b) of the Insurance
Law and section 4916.2 of the Public Health Law, certified external appeal
agents shall include in the annual report a description of each external appeal
assigned to such certified external appeal agent by the superintendent,
including a summary of the clinical justification for the agent's
determination, and any other information required by the superintendent and/or
commissioner .
(k) In no event shall
the certified external appeal agent provide the health care plan with a copy of
the insured's application for an external appeal or divulge to the health care
plan, the insured, the insured's attending physician or health care provider
the names of the clinical peer reviewers assigned to the appeal. However, such
information shall be made available upon request to and upon audit or
examination by the superintendent and commissioner. Nothing herein is intended
to preclude access to such information during court proceedings.
Notes
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