NY A07730

Establishes independent pools of physicians and professional health service providers in each medical specialty to serve as utilization review agents under the Public Health Law, Insurance Law, and Workers' Compensation Law, with applicants certifying they will make decisions fairly and without bias.

Requires random, rotating assignment of utilization review agents by geographic region from the established pools to eliminate bias, with both insurance carriers and claimants able to reject no more than two names before the next available agent is selected.

Prohibits utilization review agents from performing reviews when conflicts of interest exist, including instances where the agent or someone in their office has treated the covered person, or when the agent receives more than fifty percent of income from utilization reviews or material value from the insurance carrier.

Mandates random audits of utilization review agent records (no more than five annually), with authorization for remedial programs if three or more records are deficient, and removal from the pool after two consecutive annual audit periods with deficiencies despite remedial action.

Requires utilization review agents to cite specific pages and references to practice guidelines, peer-reviewed medical literature, scientific studies, and standard reference materials when making determinations adverse to a covered person's ongoing or concurrent care.