New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter XVIII - External Appeals Of Adverse Determinations Of Health Care Plans
Part 410 - External Appeals Of Adverse Determinations Of Health Care Plans
Section 410.13 - Audits and examinations

Universal Citation: 11 NY Comp Codes Rules and Regs ยง 410.13

Current through Register Vol. 46, No. 39, September 25, 2024

(a) The superintendent or commissioner 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 Insurance Law or title II of article 49 of the Public Health Law and this Part, 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) insured'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 insured and the insured's health care plan and, as applicable, the insured'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 superintendent or commissioner 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 Insurance Law or title II of article 49 of the Public Health Law and this Part.

(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 agents'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 insured or, as applicable, the insured's health care provider regarding the final utilization review adverse determination and the insured'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 insured to waive the health care plan's internal utilization review processes.

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