Current through Register Vol. 35, No. 18, September 24, 2024
A.
Superintendent's list. The
superintendent shall compile and maintain a list of approved IROs.
B.
IRO Requirements. To be
considered for placement on the list of approved IROs, an IRO shall:
(1) be accredited by a nationally recognized
private accrediting entity;
(2)
meet the requirements of this rule; and
(3) have quality assurance mechanisms that
ensure that clinical reviewers assigned to conduct the external review are
qualified and impartial physicians or other appropriate health care providers
who;
(a) have expertise in the treatment of
grievant's medical condition;
(b)
hold a non-restricted license in a state of the United States and, for
physicians, a current certification by a recognized medical specialty board in
the area(s) appropriate to the subject of the IRO review; and
(c) have no history of disciplinary actions
or sanctions, including loss of staff privileges or participation restrictions,
that have been taken or are pending by any hospital, governmental agency or
unit, or regulatory body that raise substantial questions about the clinical
reviewer's physical, mental or professional competence or moral
character.
(4) have
written policies and procedures that ensure:
(a) all reviews are conducted within the
timeframe specified by this rule and required notices are provided in a timely
manner;
(b) the selection of
qualified and impartial physicians or other appropriate health care
professionals to act as clinical reviewers based on the requirements of
specific cases and that the IRO employs or contracts with an adequate number of
clinical reviewers to meet this objective;
(c) the confidentiality of medical and
treatment records and clinical review criteria; and
(d) that any person employed by or under
contract with the IRO adheres to the requirements of this rule.
(5) maintain a toll-free telephone
service to receive information 24 hours a day, seven days per week basis
related to external reviews that is capable of accepting, recording or
providing appropriate instruction to incoming telephone callers during other
than normal business hours.
C.
Applicants for the IRO list.
An applicant requesting placement on the list of approved IROs shall submit for
the superintendent's review:
(1) an IRO
application form available on the OSI website;
(2) all documentation and information
requested on the application, including proof of being accredited by a
nationally recognized private accrediting entity;
(3) any applicable application fee pursuant
to §
59A-6-1(BB);
and
(4) completion of a memorandum
of understanding, to be supplied by OSI.
D.
Termination of IRO. The
superintendent shall, in the superintendent's sole discretion, terminate the
approval of an IRO if the superintendent determines that the IRO has lost its
accreditation or no longer satisfies the minimum requirements for
approval.
E.
Conflict of
interest by an IRO.
(1) An IRO may not
own or control, be a subsidiary of or in any way be owned or controlled by, or
exercise control with a health care insurer, a national, state or local trade
association of health care insurers, or a national, state or local trade
association of health care providers.
(2) Neither an IRO appointed to conduct the
independent review nor any clinical reviewer assigned by an IRO to conduct a
review may have a material, professional, familial or financial conflict of
interest with:
(a) the health care insurer
that is the subject of the IRO review;
(b) an officer, director, manager or
management employee of the health care insurer that is the subject of the IRO
review;
(c) the health benefits
plan;
(d) the plan administrator,
plan fiduciaries or plan employees;
(e) the grievant or the grievant's
representative;
(f) the grievant's
health care provider(s) or the provider's medical group, who is recommending
the service or treatment that is the subject of the review;
(g) the health care provider's medical group
or independent practice association;
(h) a health care facility where the service
would be provided; or
(i) the
developer, manufacturer, distributor, or supplier of the principal drug,
device, procedure or other service that is the subject of the appeal.
F.
Written
procedures. An IRO shall establish and maintain written procedures to
ensure that it is unbiased in addition to any other procedures required under
this rule.
G.
Availability of
records. An IRO shall keep and maintain written or electronic records
and make available upon request by OSI, any record received or reviewed during
an IRO review for a period of six years following the review.
H.
IRO's report to OSI. An IRO
shall keep and maintain written or electronic records of all IRO reviews it has
conducted under this rule and make available to OSI every calendar year on
January 15, a report that is organized by health care insurer and which
includes:
(1) the total number of reviews
conducted;
(2) the number of
reviews resolved; and of those resolved, the number resolved upholding the
adverse determination or final adverse determination of the health care
insurer;
(3) the total number
resolved reversing the adverse determination or final adverse determination of
the health care insurer;
(4) the
average length of time for the review;
(5) a summary of the types of coverages or
cases for which the review was sought, as provided in the format required by
the superintendent;
(6) the number
of reviews that were terminated as a result of a reconsideration by the health
care insurer of its adverse determination after the receipt of additional
information from the grievant; and
(7) any other information the superintendent
may request or require.
I.
Contracts with health care
insurers. Nothing in this rule precludes or shall be interpreted to
preclude a health care insurer from contracting with an approved IRO to conduct
peer or federal external reviews.
