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Text of Proposed Amendment of Part 324 of 12 NYCRR
(Amendment of the Medical Treatment Guidelines)


§ 324.1 Definitions

For purposes of this Subchapter:

§ 324.2 Medical treatment guidelines

§ 324.3 Variances

§ 324.4 Optional prior approval

§ 324.5 Conditions, treatments, or diagnostic tests not addressed by medical treatment guidelines

If the Medical Treatment Guidelines do not address a condition, treatment or diagnostic test for a part of the body covered by the Medical Treatment Guidelines, then the factors in subdivision (a) (3) of section 324.3 of this Part and relevant medical literature as described in subdivision (a) (4) of section 324.3 of this Part shall be used to determine whether the insurance carrier or Special Fund shall be obligated or not obligated to pay for the medical care at issue.

§ 324.6 Incorporation into policies, procedures and practices

Insurance carriers and Special Funds shall incorporate the Medical Treatment Guidelines set forth in section 324.2 (a) and (b) and the provisions in sections 324.3(b), 324.4(a), and 324.5 of this Part, and section 325-1.25 of Subpart 325-1 into their policies, procedures, and practices so that their utilization review and management criteria are consistent with the Medical Treatment Guidelines. Insurance carriers and Special Funds shall have certified[y] to the Chair within one hundred and twenty days of the effective date of this Part that they have done so and shall re-certify to the incorporation of the Medical Treatment Guidelines and the regulatory provisions cited in the previous sentence within sixty days of any changes to their policies, procedures, and practices. The Chair and Department of Insurance will conduct audits of insurance carriers and Special Funds with respect to the accuracy of the certifications. Each insurance carrier shall submit the policies and procedures incorporating the Medical Treatment Guidelines incorporated by reference in section 324.2 (a) and (b) and the provisions in sections 324.3 (b), 324.4 (a), and 324.5 of this Part, and section 325-1.25 of Subpart 325-1 to the Chair or Department of Insurance in connection with such audit.


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