New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter II - Administrative Rules and Regulations
Subchapter R - Health Maintenance Organizations
Part 98 - Health Maintenance Organizations
Subpart 98-2 - External Appeals Of Adverse Determinations
Section 98-2.13 - Audits and examinations

Universal Citation: 10 NY Comp Codes Rules and Regs § 98-2.13

Current through Register Vol. 47, No. 12, March 26, 2025

(a) The commissioner or superintendent or their representative(s) may examine at any time each certified external appeal agent, including any entities under contract with the certified external appeal agent for the purpose of carrying out the requirements of title II of article 49 of the Public Health Law or title II of article 49 of the Insurance Law and this Subpart, as to compliance with such requirements and the quality of services offered.

(b) All external appeal case records shall be subject to audit and examination for a period of six years from the date of the certified external appeal agent's final determination on the appeal. All documentation relating to the case shall be kept and maintained by the certified external appeal agent for no less than six years from the date of the certified external appeal agent's final determination on the appeal. Such documentation shall include, but not be limited to:

(1) procedures for credentialing clinical peer reviewers;

(2) procedures for selecting clinical peer reviewers for the case, including procedures for ensuring the absence of any prohibited material affiliation relative to clinical peer reviewers;

(3) enrollee's medical and treatment records;

(4) any other documentation received by the certified external appeal agent relative to the case;

(5) notes, comments and determinations of each clinical peer reviewer assigned to the case;

(6) written justification when more than three clinical peer reviewers are assigned to a particular case;

(7) letter of notification to the enrollee and the enrollee's health care plan and, as applicable, the enrollee's health care provider of the final determination;

(8) the names and qualifications of the clinical peer reviewer(s) that reviewed the external appeal; and

(9) a signed and notarized attestation from each clinical peer reviewer assigned to an external appeal that no prohibited material affiliation exists with respect to such external appeal.

(c) The commissioner or superintendent or their representative(s) may examine at any time each health care plan to determine compliance with the requirements of title II of article 49 of the Public Health Law or title II of article 49 of the Insurance Law and this Subpart.

(d) All external appeal case records shall be subject to audit and examination for a period of six years from the date of the certified external appeal agent's final determination on the appeal. All documentation relating to the case shall be kept and maintained by the health care plan for no less than six years from the date of the certified external appeal agent's final determination on the appeal. Such documentation shall include, but not be limited to:

(1) record of fees collected and waived;

(2) all correspondence and any other documentation received by and submitted to the certified external appeal agent assigned to the case;

(3) a copy of the notice provided by the health care plan to the enrollee or, as applicable, the enrollee's health care provider regarding the final utilization review adverse determination and the enrollee's right to request an external appeal; and

(4) a copy of the letter or other documentation of agreement between the health care plan and the enrollee to waive the health care plan's internal utilization review processes.

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