Minimum Process Requirements for Prior Authorization Utilization

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 1 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

Request Intake

§§4902(a)(6);

4903(a)(1)

• Process to conduct intake, data collection, and

perform non-clinical review functions.

• Process to accept requests by phone as well as in

writing. Optional: Fax, electronic, or web portal.

Trained staff

(non-clinical

tasks only).

Licensed

Health Care

Professional.

Information

Needed

§§4902(a)(2);

4903(a)(1),(b);

4905(k); 29 CFR

2560.503-1(f)(2)(i),

(iii)

• If more information is needed, process to request

information and monitor for timely response.

• Process to ensure request is not pended

indefinitely and determination is made even if no

response to requested information is received.

Request information

within 24 hours and allow

48 hours to submit,

including for a step

therapy protocol override

determination.

Request information within

3 business days (bd) and

allow 45 days to submit.

For a step therapy protocol

override determination,

request supporting

rationale and

documentation within 72

hours and allow 45 days to

submit.

Effective 1/1/21 for

inpatient rehabilitation

services following an

inpatient hospital

admission provided by a

hospital or skilled nursing

facility, request information

within 1 business day and

allow 45 days to submit.

Trained staff.

Licensed

Health Care

Professional.

Review

§§3242; 4329;

4902(a)(1), (3), (10),

(11)

• Process to conduct utilization review against written

clinical criteria; keep records of health professional

or clinical peer conducting review and specific

criteria used.

• Process to review a request for coverage of a non-

formulary drug (formulary exception request).

• When establishing a step therapy protocol, process

to use recognized evidence-based and peer

reviewed clinical review criteria that also takes into

account the needs of atypical patient populations

and diagnoses. When conducting utilization review

for a step therapy protocol override determination,

process to use recognized evidence-based and

peer reviewed clinical review criteria that is

Licensed

Health Care

Professional

or Clinical

Peer.

Medical

Director.

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 2 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

appropriate for the insured and the insured’s

medical condition.

Review of Mental

Health and SUD

Treatment

§§ 3216(i)(30)(D);

3216(i)(31)(E);

3216(i)(31-a);

3216(i)(35)(G);

3221(l)(5)(G);

3221(l)(6)(D);

3221(l)(7)(E);

3221(l)(7-b);

4303(g)(8);

4303(k)(4);

4303(l)(5);

4303(l-2);

4900(b);

4902(a)(9),(12)

• For utilization review of SUD treatment, process to

use an evidence-based and peer reviewed clinical

review tool that is appropriate to the age of the

patient. When conducting utilization review of SUD

treatment provided in New York, process to use an

evidence-based and peer reviewed clinical review

tool designated by the Office for Addiction Services

and Supports (OASAS) that is consistent with the

treatment service levels within the OASAS system.

• For utilization review of SUD treatment, process to

ensure that clinical peers who make adverse

determinations are either: (1) a physician who

possesses a current and valid license to practice

medicine and who specializes in behavioral health

and has experience in the delivery of SUD

treatment; or (2) a health care professional other

than a physician who specializes in behavioral

health and has experience in the delivery of SUD

treatment and, where applicable, possesses a

current and valid non-restricted license, certificate,

or registration, or if none exists, is credentialed by

the national accrediting body appropriate to the

profession.

• Process to ensure that prior authorization is not

conducted for inpatient SUD treatment provided at

facilities that are licensed, certified, or otherwise

authorized by OASAS and participate in the

issuer’s provider network.

• Process to ensure that prior authorization is not

conducted for outpatient SUD treatment provided at

facilities that are licensed, certified, or otherwise

authorized by OASAS and participate in the

issuer’s provider network.

• Process to ensure that prior authorization is not

conducted for the formulary forms of prescribed

medications covered under the policy for SUD

treatment.

Licensed

Health Care

Professional

or Clinical

Peer.

Medical

Director.

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 3 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

• For utilization review of mental health treatment,

process to use only evidence-based and peer

reviewed clinical review criteria that is appropriate

to the age of the patient, deemed appropriate and

approved for such use by the Office of Mental

Health (OMH).

• For utilization review of mental health treatment,

process to ensure that clinical peers who make

adverse determinations are either: (1) a physician

who possesses a current and valid license to

practice medicine and who specializes in

behavioral health and has experience in the

delivery of mental health treatment; or (2) a health

care professional other than a physician who

specializes in behavioral health and has experience

in the delivery of mental health treatment and,

where applicable, possesses a current and valid

non-restricted license, certificate, or registration, or

if none exists, is credentialed by the national

accrediting body appropriate to the profession.

• Process to ensure that prior authorization is not

conducted for inpatient mental health treatment for

individuals under age 18 provided at OMH-licensed

hospitals that participate in the issuer’s provider

network.

Determination

§§3242; 4329;

4902(a)(1), (4);

4903(b), (c-1), (c-2),

(c-3), (g);

29 CFR 2560.503-

1(f)(2)(i), (iii);

45 CFR

147.136(b)(2)(ii)(F),

(b)(3)(ii)(F)

• Process to ensure adverse decisions are made by

clinical peer (including denials for lack of

information).

• Process for approvals to be made by health

professional or clinical peer.

• Process to keep record of decision and set up

authorizations on systems as required.

• Process to ensure that if a decision is not made

within 3 bd of receipt of necessary information, the

failure to meet the timeframe is deemed an adverse

determination subject to appeal. In addition,

process to ensure that there will be a deemed

exhaustion of internal claims and appeals

processes if the Agent fails to adhere to utilization

review requirements and timeframes unless it is a

If request is complete,

within 72 hours of receipt

of request. If request is

not complete, within 48

hours of the earlier of

receipt of necessary

information or the end of

the 48 hour period.

For an expedited step

therapy protocol override

determination, if request

includes supporting

documentation and

rationale, within 24 hours

If request is complete,

within 3 bd of receipt of the

request. If request is not

complete, within the earlier

of 3 bd of receipt of

necessary information, 15

days of receipt of partial

information, or 15 days of

the end of the 45-day

period if no information

received.

For a standard step

therapy protocol override

determination, within the

Approvals:

Licensed

Health Care

Professional

or Clinical

Peer.

Denials:

Clinical Peer.

Medical

Director.

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 4 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

de minimis violation that does not cause prejudice

or harm to the insured so long as the Agent

demonstrates that the violation was for good cause

or due to matters beyond the control of the Agent

and that the violation occurred in the context of an

ongoing, good faith exchange of information

between the Agent and the insured. The insured

may request a written explanation of the violation

from the Agent, and the Agent must provide such

explanation within 10 days, including a specific

description of its bases, if any, for asserting that the

violation should not cause the internal claims and

appeals process to be deemed exhausted.

• For a step therapy protocol override determination,

process to ensure that if a decision is not made

within 24 hours of receipt of supporting rationale

and documentation for expedited reviews, or 72

hours of receipt of supporting rationale and

documentation for standard reviews, the failure to

meet the timeframe is deemed an approval of the

coverage.

of receipt of request. If

request does not include

supporting rationale and

documentation, within the

earlier of 24 hours of

receipt of supporting

rationale and

documentation or 48

hours of the end of the 48

hour period.

For an expedited

formulary exception

request, within 24 hours

of receipt of the request.

For court ordered

treatment, within 72 hours

of receipt of the request.

Effective 1/1/21 for

inpatient rehabilitation

services following an

inpatient hospital

admission provided by a

hospital or skilled nursing

facility, if the request is

complete, within the

earlier of 72 hours or 1 bd

from receipt of the

request. If request is not

complete, within the

earlier of 48 hours or 1 bd

of the receipt of

necessary information. If

no information is

received, 48 hours from

the end of the 48-hour

period.

earlier of 72 hours of

receipt of the supporting

rationale and

documentation, 15 days of

receipt of partial

information, or 15 days

after the end of the 45-day

period if no information

received.

For a standard formulary

exception request, within

72 hours of receipt of the

request.

For court ordered

treatment, within 72 hours

of receipt of the request.

Effective 1/1/21 for

inpatient rehabilitation

services following an

inpatient hospital

admission provided by a

hospital or skilled nursing

facility, if the request is

complete, within 1 bd of

receipt of the request. If

request is not complete,

within the earlier of 1 bd of

receipt of necessary

information, 15 days of

receipt of partial

information, or 15 days of

the end of the 45-day

period if no information

received.

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 5 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

Verbal Notice

§§4902(a)(4);

4903(b); 29 CFR

2560.503-1(g)

• Process for reasonable effort to contact insured

and provider by phone or in person to transmit

approval or denial of request and record contact or

attempts.

• A reasonable effort to contact by phone is defined

as at least two attempts by phone. Each attempt

must be at least one hour apart to be considered a

new attempt. The Agent must wait until someone

answers the phone, the call goes to voicemail, or

ten rings have occurred (in that order). If the call

goes to voicemail, the Agent must leave a

voicemail.

• If the insured states in writing that they do not want

to receive phone calls regarding determinations,

the UR agent does not need to provide verbal

notice.

At time of determination.

Trained Staff

may transmit

notice

(adverse

determination

s must be

made by

clinical peer).

Licensed

Health Care

Professional.

Written Notice

§§3242; 4329;

4902(a)(4), (5);

4903(b), (e);

29 CFR 2560.503-

1(g)(2);

45 CFR 156.122(c)

• Process to create and send notice of approvals and

denials to insured and provider in writing (optional,

if agreed upon in advance: fax, electronic, or for

providers, web portal).

• To the extent practicable, process to transmit

written notification to the provider electronically in a

manner and form agreed upon by the parties.

• Process to ensure all required information is

included in notice.

• For formulary exception request denials, process to

ensure that the first denial is considered the final

adverse determination (FAD) and all required

information is included in FAD, including the

name(s) of clinically appropriate prescription drugs

on the issuer’s formulary to treat the insured.

If request is complete,

within 3 bd of receipt of

request. If request is not

complete, within the

earlier of 3 bd of receipt

of the information or 3

days after the verbal

notification.

For an expedited step

therapy protocol override

determination, if request

is complete, within 24

hours of receipt of

request. If request is not

complete, within the

earlier of 24 hours of

receipt of supporting

rationale and

documentation or 3 days

after the verbal

notification.

If request is complete,

within 3 bd of receipt of the

request. If request is not

complete, within the earlier

of 3 bd of receipt of

necessary information, 15

days of receipt of partial

information, or 15 days of

the end of the 45-day

period if no information

received.

For a step therapy protocol

override determination,

within the earlier of 72

hours of receipt of the

supporting rationale and

documentation, 15 days of

receipt of partial

information, or 15 days

after the end of the 45-day

period if no information

received.

Trained Staff

may transmit

notice

(adverse

determination

s must be

made by

clinical peer).

Licensed

Health Care

Professional.

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 6 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

For an expedited

formulary exception

request, within 3 bd of

receipt of the request.

For court ordered

treatment, within 3 bd of

receipt of the request.

Effective 1/1/21 for

inpatient rehabilitation

services following an

inpatient hospital

admission provided by a

hospital or skilled nursing

facility, within the earlier

of 72 hours or 1 bd if the

request is complete. If

request is not complete,

within the earlier of 48

hours or 1 bd of the of

receipt of necessary

information. If no

information is received,

48 hours from the end of

the 48-hour period.

For a standard formulary

exception request, within 3

bd of receipt of the

request.

For court ordered

treatment, within 3 bd of

receipt of the request.

Effective 1/1/21 for

inpatient rehabilitation

services following an

inpatient hospital

admission provided by a

hospital or skilled nursing

facility, if the request is

complete, within 1 bd of

receipt of the request. If

request is not complete,

within the earlier of 1 bd of

receipt of necessary

information, 15 days of

receipt of partial

information, or 15 days of

the end of the 45-day

period if no information

received.

Reconsideration

(Peer to Peer)

§§4902(a)(1),

4903(f)

• Where case was not previously discussed with the

insured’s provider, process to accept

communication from providers and refer to clinical

peer for review of decision.

• Upon outcome of reconsideration, process to

resend initial adverse determination or approval

notice to insured and provider.

• Process to maintain record of decision.

1 bd of request.

Clinical Peer.

Medical

Director.

Time Allowed to File Appeal

§4904(c), 29 CFR 2560.503-1(h)(3)(i)

Must allow insureds or designees180 days from receipt

of adverse determination.

Appeal Intake

§§3242; 4329;

4902(a)(4),

• Process to conduct intake, data collection, and

perform non-clinical review functions.

Trained staff.

Licensed

Health Care

Professional.

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 7 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

4904(a),(a-1), (b),

(c);

45 CFR

147.136(b)(3)(ii)(G);

45 CFR 156.122(c)

• Process to accept appeals by phone and in writing.

Optional: Fax, electronic, web portal.

• Process to accept appeal of a determination that an

out-of-network service is not materially different

from an alternate in network service.

• Process to accept appeal of a determination that a

referral should not be granted for an out-of-network

provider because an in-network provider is

available.

• Process to expedite review when Agent determines

or provider believes immediate appeal is

warranted.

• For group insurance only, process to accept a

standard appeal following an upheld expedited

appeal (if standard appeal upheld, a new FAD is

issued).

• An appeal of a formulary exception denial is not

permitted as the initial denial is the FAD.

Written

Acknowledgement

§§4902(a)(2);

4904(c)

• Process to ensure written acknowledgement is sent

to insured; this notice may be combined with

appeal determination.

Not required.

Within 15 days.

Trained staff.

Licensed

Health Care

Professional.

Information

Needed

§§4902(a)(2);

4904(a-1), (a-2), (b),

(c); 4905(k);

11 NYCRR 410.9(b)

• If more information needed, process to request

missing information from insured and provider in

writing and monitor for timely response; ensure

appeal is not pended indefinitely and determination

is made even if no response to requested

information is received.

• For an appeal of an out-of-network service denial

or an out-of-network referral denial, process to

request information needed as per § 4904(a-1) and

(a-2) if submitted information is incomplete.

Request additional

information immediately

by phone or fax, follow

with written request.

Request additional

information within 15 days;

if partial response, written

request for missing

information sent in 5 bd.

Trained staff.

Licensed

Health Care

Professional.

Review

§§4902(a)(1), (3);

4904(b),(c),(d);

29 CFR 2560.503-

1(h)(3)

• If appeal is expedited, process to ensure access to

a clinical peer within 1 bd.

• Process to conduct utilization review against written

clinical criteria; keep records of clinical peer

conducting review and specific criteria used.

• Process to ensure appeal is conducted by clinical

peer other than clinical peer who made initial

Clinical Peer

(who did not

make initial

decision and

is not

subordinate

of clinical

Medical

Director.

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 8 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

determination and the clinical peer making the

determination is not the subordinate of the clinical

peer who made the initial determination.

peer who

made initial

determination

Determination

§§4902(a)(4);

4904(b),(c), (d), (e);

29 CFR 2560.503-

1(h)(3)(ii); (i)(2)(i),

(ii); 45 CFR

147.136(b)(2)(ii)(C)(

2); (b)(3)(ii)(C)(2)

• Process to ensure adverse appeal decision is

made by clinical peer other than clinical peer who

made initial determination and the clinical peer

making the appeal determination is not the

subordinate of the clinical peer who made the initial

determination. Process to keep record of decision

and set up authorizations on systems as required.

• Process to ensure that before the Agent issues a

FAD based on a new or additional rationale, the

insured is provided, free of charge, with the

rationale as soon as possible and sufficiently in

advance of the date on which the FAD is required

to be provided to give the insured a reasonable

opportunity to respond prior to that date.

• Process to ensure that if a decision is not made

within 2 bd of receipt of necessary information for

expedited appeals, or 60 days of receipt of

necessary information for standard appeals, the

failure to meet the timeframe is deemed an

approval of the coverage.

The lesser of 72 hours of

receipt of the appeal or 2

bd after all information.

30 days of receipt of the

appeal for one level of

appeal or 15 days of

receipt of each appeal for

two levels of appeal.

Clinical Peer

(who did not

make initial

decision and

is not

subordinate

of clinical

peer who

made initial

determination

Medical

Director.

Written Notice

§§4902(a)(4);

4904(c),(d);

11 NYCRR 410.9(e),

(f);

29 CFR 2560.503-

1(i)(2)(i), (ii)

• Process to create and send notice of approvals and

denials (FAD) to insured and provider in writing

(optional, if agreed upon in advance: fax,

electronic, or for providers, web portal)

• Process to ensure all required information is

included in FAD notice.

24 hours of determination

but no later than 72 hours

from receipt of appeal.

2 bd of determination but

no later than 30 days of

receipt of the appeal for

one level of appeal or 15

days of receipt of each

appeal for two levels of

appeal.

Trained Staff

may transmit

notice

(adverse

determination

s must be

made by

clinical peer).

Licensed

Health Care

Professional.

Level Appeal (If

Offered for Group

Coverage Only)

§§4902; 4904(b)(2);

11 NYCRR 410.9(e);

29 CFR 2560.503-

1(h)(3)(ii); (i)(2)(i),

• Process to ensure that FAD states in bold “that

time to file External Appeal begins upon receipt of

the final adverse determination of the 1

level

appeal, regardless of whether or not a 2

level

appeal is requested, and that by choosing to

request a 2

level internal appeal, the time may

expire for the insured to request an external

appeal.”

72 hours of receipt of 1

level appeal request (1

and 2

level expedited

appeals must be

completed within 72

hours total).

15 days of receipt of the

appeal.

Clinical Peer

(who did not

make initial

decision and

is not

subordinate

of clinical

peer who

Medical

Director.

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Utilization Review Agent Report

Division of Insurance, Health Bureau Application and Attestation

Attachment A: Minimum Process Requirements for Prior Authorization Utilization Review

DFS (11/20) Attachment A-1 Page 9 of 9

Function Required Procedure

Timeframe

Responsible

Party

Oversight

Expedited/ Urgent

Standard

(ii); 45 CFR

147.136(b)(3)(ii)(G)

• If Agent considers standard appeal following an

upheld expedited appeal a 2

level appeal, the 2

level appeal must meet requirements for standard

appeal and, if upheld, must result in a FAD with

external appeal rights.

• Process to accept and review 2

level appeal for

group insurance only. Individual insurance must

only have 1 level of internal appeal.

made initial

determination