NY A06648

Prohibits health plans from reversing medical necessity determinations previously made by utilization review or external appeal agents through retrospective audits, except in cases of fraud

Prohibits health plans from downcoding or bundling claims in ways that effectively reverse or alter medical necessity determinations, including level of care decisions

Expands emergency services exempt from prior authorization to include mental health and substance use disorder services provided by mobile crisis response teams and crisis stabilization centers

Requires clinical review criteria used for utilization review of mental health, substance use disorder, and step therapy determinations to be fully consistent with medical and scientific evidence and to publicly identify all authors, reviewers, and editors

Mandates that the Office of Mental Health designate clinical review criteria for mental health level of care determinations, with inter-rater reliability testing required prior to implementation