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This entry was published on 2014-09-22
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Standards for certification
Insurance (ISC) CHAPTER 28, ARTICLE 49, TITLE 2
§ 4912. Standards for certification. (a) The superintendent shall
develop an application for certification. At a minimum, applicants shall

(1) a description of the qualifications of the clinical peer reviewers
retained to conduct external appeals of final adverse determinations
including such reviewers' current and past employment history and
practice affiliations;

(2) a description of the procedures employed to ensure that clinical
peer reviewers conducting external appeals are:

(i) appropriately licensed, registered or certified;

(ii) trained in the principles, procedures and standards of the
external appeal agent; and

(iii) knowledgeable about the health care service which is the subject
of the final adverse determination under appeal;

(3) a description of the methods of recruiting and selecting impartial
clinical peer reviewers and matching such reviewers to specific cases;

(4) the number of clinical peer reviewers retained by the external
appeal agent, and a description of the areas of expertise available from
such reviewers and the types of cases such reviewers are qualified to

(5) a description of the policies and procedures employed to protect
the confidentiality of individual medical and treatment records in
accordance with applicable state and federal laws;

(6) a description of the quality assurance program established by the
external appeal agent pursuant to paragraph three of subsection (b) of
this section;

(7) the names of all corporations and organizations owned or
controlled by the external appeal agent, or which owns or controls such
agent, and the nature and extent of any such ownership or control;

(8) the names and biographies of all directors, officers, and
executives of the external appeal agent;

(9) an experimental and investigational treatment review plan to
conduct appeals pursuant to subparagraph (B) of paragraph four of
subsection (b) of section four thousand nine hundred fourteen of this
title; and

(10) a description of the fees to be charged by agents for external

(b) The superintendent shall, at a minimum, require an external appeal
agent to:

(1) appoint a medical director, who is a physician in possession of a
current and valid non-restricted license to practice medicine. Such
director shall be responsible for the supervision and oversight of the
external appeal process;

(2) develop written policies and procedures governing all aspects of
the appeal process, including, at a minimum:

(i) procedures to ensure that appeals are conducted within the time
frames specified in section four thousand nine hundred fourteen of this
title, and any required notices are provided in a timely manner;

(ii) procedures to ensure the selection of qualified and impartial
clinical peer reviewers. Such reviewers shall be qualified to render and
impartial determinations relating to the health care service which is
the subject of the final adverse determination under appeal;

(iii) procedures to ensure the confidentiality of medical and
treatment records and review materials; and

(iv) procedures to ensure adherence to the requirements of this title
by any contractor, subcontractor, subvendor, agent or employee
affiliated by contract or otherwise with such external appeal agent;

(3) establish a quality assurance program. Such program shall include
written descriptions, to be provided to all individuals involved in such
program, of the organizational arrangements and ongoing procedures for
the identification, evaluation, resolution and follow-up of potential
and actual problems in external appeals performed by the external appeal
agent and to ensure the maintenance of program standards pursuant to
this section;

(4) establish a toll-free telephone service to receive information on
a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant
to this title. Such system shall be capable of accepting, recording or
providing instruction to incoming telephone calls during other than
normal business hours;

(5) develop procedures to ensure that:

(i) appropriate personnel are reasonably accessible not less than
forty hours per week during normal business hours to discuss patient
care and to allow response to telephone requests, and

(ii) response to accepted or recorded messages shall be made not less
than one business day after the date on which the call was received; and

(6) be accredited by a nationally recognized private accrediting

(c) No entity shall be qualified to submit such request for
application if it owns or controls, is owned or controlled by, or
exercises common control with, any of the following:

(1) any national, state or local illness, health benefit or public
advocacy group;

(2) any national, state or local society or association of hospitals,
physicians, or other providers of health care services; or

(3) any national, state or local association of health care plans.

(d) A health care plan shall transmit, and an external appeal agent
shall be authorized to receive and review, an insured's medical and
treatment records in order to conduct an external appeal pursuant to
this title.

(e) An external appeal agent shall provide ready access to the
superintendent to all data, records, and information collected and
maintained concerning such agent's external appeal activities.

(f) An external appeal agent shall agree to provide the superintendent
such data, information, and reports as the superintendent determines
necessary to evaluate the external appeal process established pursuant
to this title.

(g) The superintendent shall provide, upon the request of any
interested person, a copy of all non-proprietary information filed with
the superintendent by the external appeal agent. The superintendent may
charge a reasonable fee to the interested person for reproducing the
requested information.