NY A07268

Requires utilization review programs to use recognized evidence-based and peer-reviewed clinical review criteria that account for typical patient populations and diagnoses, amending both Public Health Law and Insurance Law sections 4902.

Reduces pre-authorization notification timeframe from three business days to seventy-two hours for standard health care services, and to twenty-four hours for urgent medical conditions that place patient health in serious jeopardy.

Maintains one business day notification requirement for inpatient rehabilitation services following inpatient hospital admission at hospitals or skilled nursing facilities.

Requires pre-authorization approval notifications to identify in-network or out-of-network status, hold-harmless provisions, dollar amounts to be paid for out-of-network services, and information on calculating anticipated out-of-pocket costs.

Makes pre-authorization approvals valid for the full duration of prescribed treatment, including authorized refills and the entire course of treatment for the specific approved condition.