§ 4901. Registration of utilization review agents. 1. Every
utilization review agent who conducts the practice of utilization review
shall biennially register with the commissioner and report, in a
statement subscribed and affirmed as true under the penalties of
perjury, the information required pursuant to subdivision two of this
section.

2. Such report shall contain a description of the following:

(a) The utilization review plan;

(b) Those circumstances, if any, under which utilization review may be
delegated to a utilization review program conducted by a facility
licensed pursuant to article twenty-eight of this chapter or pursuant to
article thirty-one of the mental hygiene law;

(c) The provisions by which an enrollee, the enrollee's designee, or a
health care provider may seek reconsideration of, or appeal from,
adverse determinations by the utilization review agent, in accordance
with the provisions of this title, including provisions to ensure a
timely appeal and that an enrollee, the enrollee's designee, and, in the
case of an adverse determination involving a retrospective
determination, the enrollee's health care provider, is informed of their
right to appeal adverse determinations;

(d) Procedures by which a decision on a request for utilization review
for services requiring preauthorization shall comply with timeframes
established pursuant to this title;

(e) A description of an emergency care policy, which shall include the
procedures under which an emergency admission shall be made or emergency
treatment shall be given;

(f) A description of the personnel utilized to conduct utilization
review including a description of the circumstances under which
utilization review may be conducted by:

(i) administrative personnel,

(ii) health care professionals who are not clinical peer reviewers,
and

(iii) clinical peer reviewers;

(g) A description of the mechanisms employed to assure that
administrative personnel are trained in the principles and procedures of
intake screening and data collection and are appropriately monitored by
a licensed health care professional while performing an administrative
review;

(h) A description of the mechanisms employed to assure that health
care professionals conducting utilization review are:

(i) appropriately licensed, registered or certified; and

(ii) trained in the principles, procedures and standards of such
utilization review agent;

(i) A description of the mechanisms employed to assure that only a
clinical peer reviewer shall render an adverse determination;

(j) Provisions to ensure that appropriate personnel of the utilization
review agent are reasonably accessible by toll-free telephone:

(i) not less than forty hours per week during normal business hours,
to discuss patient care and allow response to telephone requests, and to
ensure that such utilization review agent has a telephone system capable
of accepting, recording or providing instruction to incoming telephone
calls during other than normal business hours and to ensure response to
accepted or recorded messages not later than the next business day after
the date on which the call was received; or

(ii) notwithstanding the provisions of subparagraph (i) of this
paragraph, not less than forty hours per week during normal business
hours, to discuss patient care and allow response to telephone requests,
and to ensure that, in the case of a request submitted pursuant to
subdivision three of section forty-nine hundred three of this title or
an expedited appeal filed pursuant to subdivision two of section
forty-nine hundred four of this title, on a twenty-four hour a day,
seven day a week basis;

(k) The policies and procedures to ensure that all applicable state
and federal laws to protect the confidentiality of individual medical
and treatment records are followed;

(l) A copy of the materials to be disclosed to an enrollee or
prospective enrollee pursuant to this title and section forty-four
hundred eight of this chapter;

(m) A description of the mechanisms employed by the utilization review
agent to assure that all contractors, subcontractors, subvendors, agents
and employees affiliated by contract or otherwise with such utilization
review agent will adhere to the standards and requirements of this
title; and

(n) A list of the payors for which the utilization review agent is
performing utilization review in this state.

3. Upon receipt of the report, the commissioner shall issue an
acknowledgment of the filing.

4. A registration issued under this title shall be valid for a period
of not more than two years, and may be renewed for additional periods of
not more than two years each.

5. A health maintenance organization licensed pursuant to article
forty-three of the insurance law or certified under article forty-four
of this chapter shall not be required to register as a utilization
review agent, provided that such health maintenance organization has
otherwise provided the information required pursuant to subdivision two
of this section to the commissioner.

6. The clinical review criteria and standards contained within the
utilization review plan and the list of payors required pursuant to
paragraph (n) of subdivision two of this section shall not be subject to
disclosure pursuant to the provisions of article six of the public
officers law.