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 98-2.4 - Certification of external appeal agents

Universal Citation: 10 NY Comp Codes Rules and Regs § 98-2.4

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

(a) External appeal agents shall be certified jointly by the commissioner and superintendent pursuant to section 4912 of the Public Health Law, section 4912 of the Insurance Law and the following:

(1) the applicant has demonstrated to the satisfaction of the commissioner and the superintendent that it has access to a pool of clinical peer reviewers sufficient to reasonably assure that appropriately qualified reviewers will be available on a timely basis for all appeals allowed by section 4910 of the Public Health Law and section 4910 of the Insurance Law and to avoid or minimize conflicts of interest pursuant to section 98-2.6 of this Subpart; and

(2) the applicant has demonstrated its capability to comply with all applicable laws, rules, regulations, contractual terms, policies and standards as set forth in section 4912 of the Public Health Law and section 4912 of the Insurance Law and as required by the commissioner and superintendent.

(b) Applicants for certification as external appeal agents shall submit two originals and seven copies of the application to the commissioner in the form and manner prescribed jointly by the commissioner and the superintendent. Upon receipt of the application for certification, the commissioner shall transmit copies of such application to the superintendent for review.

(c) No applicant shall be certified as an external appeal agent unless the applicant's proposed fees for external appeals are determined to be reasonable by the commissioner and superintendent.

(d) In order to be certified as an external appeal agent, an applicant shall consent to cooperate in court proceedings relevant to its role as a certified external appeal agent.

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