Utilization Review Licensing in New York

A nurse holding up a broken patients arm.

Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in New York. For assistance with licensing, please contact us to learn about our software and managed license services.

New York Utilization Review Agent Report

Type of Review:

Medical Utilization Review

Agency:New York Department of Financial Services
Law:

New York Stat ISC § 4901

Foreign Qualification is Prerequisite:Yes

Initial Registration

Form:

UR Agent Report Application and Attestation Form

Agency Fee:

$0

Required Attachments:
  • Set of UR policies and procedures, including UR plan, demonstrating Agent’s ability to carry out the relevant requirements of Insurance Law
  • Certificate of Incorporation in New York State or other documentation that the Agent has been approved by the Secretary of State to do business in New York State
  • Corporate organization chart demonstrating the position of the Agent, subsidiaries, and any parent organizations in the corporate structure (an internal organization chart is not required)
  • List of all insurers and/or municipal cooperative health benefit plans for which the Agent is performing utilization review in New York State and/or anticipated contract date
  • URAC Certificate (if applicable)
  • Template notice letters
  • External Appeal Standard Description and Application

Registration Renewal

Form:

UR Agent Report Application and Attestation Form (Renewal)

Agency Fee:

$0

Due:

Biennially by the registration anniversary date.

New York Resources

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Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

Revised February 22, 2021. Complete data last reviewed February 22, 2021.
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