Utilization Review Agent Report Submission Instructions

A Utilization Review Agent is any insurer subject to Insurance Law Articles 32 or 43 (insurers) and any municipal cooperative health benefit plan certified pursuant to Insurance Law Article 47 performing utilization review (UR) on their own behalf and any independent utilization review agent performing UR under contract with such insurer or municipal cooperative health benefit plan.  An independent utilization review agent must file a report with the Department of Financial Services (DFS) prior to contracting with any such insurer or municipal cooperative health benefit plan.  All UR agents must file a UR report with DFS every two (2) years pursuant to Insurance Law Article 49. 

Types of Applications

The application types are:  New, Renewal, Modifications, or Name Change.  Answer all questions on the application.  Attach additional pages and requested documentation as necessary. 

New Application.  A New UR Agent application is submitted when a UR Agent has not previously filed a UR Agent Application with DFS.  All application sections must be completed.  Please note that the UR functions selected in Section E must align with the information submitted in Section F. 

Renewal.  A Renewal application must be submitted by the renewal date provided in the prior UR Agent Application filing letter sent by DFS. The UR Agent Application Sections A, B, C, D, E, and H must be completed.  Application Sections F and G must be completed if material changes have been made since the prior application filing.  Only the revised portions of application Sections F and G need to be completed.  The UR policies and procedures that have materially changed since the last submission as indicated in Sections F and G must be submitted and highlighted to show the revisions.

Modification.  A Modification application should be submitted if the UR functions in Section E of the application change before the next UR Agent filing date. The UR Agent Application Sections A, B, C, D, E, and H must be completed.  Application Sections F and G must be completed to reflect the modification and include any other material changes that have been made since the prior application.  Only the revised portions of application Sections F and G need to be completed.  The UR policies and procedures that have materially changed since last submission as indicated in Sections G and H must be submitted and highlighted to show the revisions. 

Name Change.  A Name Change application should be submitted if the UR Agent’s name changes.  The UR Agent Application sections A, B, C, D, E, and H must be completed.  Application sections F and G should be completed if material changes have been made since the prior application.  Only the revised portions of application sections F and G need to be completed.  The UR policies and procedures that have been materially changed since last submission must be submitted and highlighted to show revisions.  If there are no changes to the UR Agent application other than the name change, sections F and G do not need to be completed.

Submission Requirements

The UR Agent Application submission contains the following:

  • Completed Application and Attestation, signed by the Chief Executive Officer.
  • Complete set of UR policies and procedures, including the UR plan, demonstrating Agent’s ability to carry out the relevant requirements of Insurance Law Articles 32, 43, and 49; 11 NYCRR Part 410; 42 USC § 300gg-19; 42 USC § 300gg-26; 29 USC § 1185a; 45 CFR Parts 146 and 147; and 29 CFR Parts 2560.503-1 and 2590.715-2719 (or, for renewals and modifications, policies and procedures that have been materially changed since last submission, highlighted to show revisions).  The UR policies and procedures must comply with Attachments A found in the Resources section below. 
  • 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, that comply with the Initial Determination Notice Requirements and Final Adverse Determination Notice Requirements, if applicable.

Submission

The signed UR Agent Application and Attestation, if in PDF format, and supporting documentation may be submitted electronically.  If the submission is too large for email, contact DFS to submit via the DFS Web Portal.

A hard copy or CD may be mailed to:

NYS Department of Financial Services
Insurance Division, Health Bureau
One Commerce Plaza
Albany, New York  12257
Attn:  UR Agent Report

List of Insurers and Municipal Cooperative Health Benefit Plans

UR Agent applications must include a list all insurers and/or municipal cooperative health benefit plans for which the Agent is performing utilization review in New York State.  If the Agent does not currently have a contract with a New York insurer or municipal cooperative health benefit plan but expects to shortly, it should indicate the anticipated contract date.  If the Agent does not have a contract with any New York insurer or municipal cooperative health benefit plan, it should not file a report with DFS.  For example, if the Agent only contracts with self-insured plans, it should not file with DFS.  UR Agent applications will be returned and not placed on file if the Agent does not have any contracts or does not expect to have any contracts with insurers or municipal cooperative health benefit plans.

UR Agents Subject to Other Agencies.

UR Agents intending to contract with managed care organizations certified pursuant to Public Health Law Article 44 or Workers’ Compensation Preferred Provider Organizations as provided by 10 NYCRR Part 732 must register with the New York State Department of Health (DOH) pursuant to Public Health Law Article 49.  This includes UR Agents performing utilization review for DOH programs, such as Medicaid Managed Care plans, managed long-term care plans, Child Health Plus, and the Essential Plan.  Contact DOH for more information on registering as a UR Agent with DOH.  Agents who perform UR for Medicare Advantage plans should contact the Centers for Medicare & Medicaid Services for any registration requirements.

External Appeal Application and Standard Description

UR Agents must provide the New York External Appeal Application and Standard Description with a notice of a final adverse determination.  A hard copy of the application and instructions are available at File an External Appeal.  Please ensure that the most recent version of the External Appeal Application and Instructions is being used.

Cybersecurity Regulation

See the Cybersecurity Resource Center for information regarding the applicability of the Cybersecurity Regulation on UR Agents.  Questions on the Cybersecurity Regulation should be sent here.

Questions on the UR Agent Application

Email DFS or call (518) 486-7815.

Resources

The following documents are in PDF format.