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 98-2.5 - Certification requirements

Universal Citation: 10 NY Comp Codes Rules and Regs § 98-2.5

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

Applicants for certification as external appeal agents shall be required to submit a signed and notarized application to the commissioner, in the form and manner prescribed jointly by the commissioner and the superintendent. Such application shall include the requirements of section 4912 of the Public Health Law and Insurance Law and the following:

(a) A description of the applicant's organizational structure and capability to operate a statewide external appeal program, including:

(1) certificate of incorporation, articles of organization and by-laws or operating agreement of the applicant and, as applicable, the applicant's holding company or parent company;

(2) the applicant's organizational chart; and

(3) any existing or proposed relationships between the applicant and any health care services entities, health care providers and management service organizations. A certified external appeal agent shall not delegate any management function related to external appeal activities pursuant to title II of article 49 of the Public Health Law and the Insurance Law to a management service organization or any other entity.

(b) Identification of management staff and a description of such management staff's responsibilities. Each member of the management staff shall provide personal qualifying information, in the form and manner prescribed jointly by the commissioner and the superintendent.

(c) The chief executive officer of the external appeal agent shall complete an attestation, also described in section 98-2.6(b) of this Subpart, which affirms, under penalty of perjury, that:

(1) the applicant for certification as an external appeal agent does not own or control, is not owned or controlled by and does not exercise common control with any national, State or local illness, health benefit or public advocacy group, society or association of hospitals, physicians or other providers of health care services or association of health care plans; and

(2) the external appeal entity, including the medical director and all owners, officers, directors and management employees of such entity has no material professional affiliation, material familial affiliation, material financial affiliation or other affiliation proscribed by section 98-2.6 of this Subpart with any health care plan, any owner, officer, director or management employee of any health care plan, any health care provider, physician's medical group, independent practice association or provider of pharmaceutical products or services or durable medical equipment, any health care facility, or any developer or manufacturer of health services, except as specifically listed in an attachment to the attestation.

(d) Information concerning the governing board of the applicant, including roles and responsibilities, identification of the board members and a description of their qualifications.

(e) A description of the clinical peer reviewer network, including an assessment of the network's adequacy to provide statewide external appeal services.

(f) The current financial condition of the applicant, including a certified financial statement, a statement of revenues and expenses, a balance sheet and methods to repay any indebtedness, sources of capitalization and documentation of accounts, assets, reserves and deposits.

(g) The process for ensuring that clinical peer reviewers, when making an external appeal determination concerning medical necessity, consider the clinical standards of the health care plan, the information provided concerning the enrollee, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the Federal government, national or professional medical societies, boards and associations.

(h) Policies and procedures for processing external appeals, including:

(1) a description and a chart or diagram of the sequence of steps through which an external appeal will move from receipt of the external appeal by the certified external appeal agent through notification to the enrollee and the enrollee's health care plan regarding the external appeal determination. Such description shall take into account the requirements of section 4914 of the Public Health Law and Insurance Law and section 98-2.10(a)-(h) and (k) of this Subpart; and

(2) procedures for ensuring that no prohibited material affiliation exists with respect to the clinical peer reviewer(s) assigned to each external appeal, pursuant to section 98-2.6 of this Subpart. Such procedures shall include, for each clinical peer reviewer assigned to review the external appeal, a requirement for 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 98-2.6(e), (f) and (h) of this Subpart. Such attestation shall be in such form as prescribed by the commissioner and superintendent and must be maintained on file with the certified external appeal agent.

(i) A description of the fees which shall reflect the total amount that will be charged by the certified external appeal agent for external appeals, inclusive of indirect costs, administrative fees and incidental expenses, and a description of the methodology used to calculate the fees. Fees shall be approved for use for two years. Any proposed change in fees must be prior approved by the commissioner and the superintendent.

(j) A description of the certified external appeal agent's ability to accept requests for external appeals, provide requisite notifications, screen for material affiliations, respond to calls from the State and meet other requirements on a seven day per week basis.

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