Current through Register Vol. 35, No. 18, September 24, 2024
A.
Independent decision. In reaching its decision, the IRO is not
bound by the prior decision of the health care insurer. In addition to the
documents and information provided to the IRO by the health care insurer and
the grievant and to the extent such documents are available, each reviewer
shall consider the following in reaching its decision:
(1) the grievant's medical records;
(2) the attending health care professional's
recommendation;
(3) consulting
reports from appropriate health care professionals and other documents
submitted by the health care insurer, the grievant, or the treating health care
professional;
(4) the terms of
coverage under the applicable health benefit plan to ensure that the IRO's
decision is not contrary to the terms of coverage;
(5) the most appropriate practice guidelines,
which shall include applicable evidence-based standards and may include any
other practice guidelines developed by the federal government, national or
professional medical societies, boards and associations;
(6) any applicable clinical review criteria
and policies developed and used by the health care insurer; and
(7) the opinion of the IRO's clinical
reviewer(s) after considering the information received.
B.
Opinion of clinical reviewer.
Each clinical reviewer selected shall provide an opinion to the assigned IRO as
to whether the recommended or requested health care service should be covered
as follows:
(1) for a standard external
review, each clinical reviewer shall provide a written opinion to the IRO
within the time constraints set by this rule;
(2) for an expedited external review, each
clinical reviewer shall provide an opinion orally or in writing to the IRO as
expeditiously as the covered person's medical condition or circumstances
requires. If the opinion is provided orally, each clinical reviewer shall
provide a written opinion to the IRO within 48 hours after providing the oral
opinion; and
(3) each clinical
reviewer's written opinion shall include the following information:
(a) a description of the covered person's
medical condition;
(b) whether
there is sufficient evidence to demonstrate that the requested health care
service is more likely than not to be more beneficial to the covered person
than any available standard health care services and that the adverse risks of
the requested health care service would not be substantially increased over
those of available standard health care services;
(c) a description and analysis of any medical
or scientific evidence considered in reaching the opinion;
(d) a description and analysis of any
evidence-based standards;
(e) the
reviewer's rationale for the opinion; and
(f) whether the recommended or requested
health care service has been approved by the federal food and drug
administration, if applicable, for the condition.
C.
Decision of the
IRO. Based upon the opinion of each clinical reviewer, the IRO shall
issue notice of its decision in the manner set forth in this rule.
(1) If a majority of clinical reviewers
recommend that the requested health care service should be covered, the IRO
shall reverse the health care insurer's adverse determination.
(2) If a majority of clinical reviewers
recommend that the requested health care service should not be covered, the IRO
shall uphold the health care insurer's adverse determination.
D.
Content of IRO's
notice. Notice of the IRO's decision shall be sent to the grievant, the
provider, the health care insurer, and the superintendent and shall include:
(1) a general description of the reason for
the request for external review;
(2) the date the IRO was appointed;
(3) the date the review by the IRO was
completed;
(4) the principal
reason(s) for its decision, including any applicable evidence-based standards
that were the basis for the decision;
(5) reference to the evidence or
documentation that was considered in reaching the decisions;
(6) the rationale for the decision;
and
(7) the written opinion of each
clinical reviewer as to whether the recommended or requested health care
service or treatment should be covered and the rationale for each reviewer's
recommendation.
E.
Binding decision. The decision of the IRO is binding upon the
health care insurer except to the extent that the health care insurer may
pursue other remedies under applicable state and federal law. The decision is
also binding upon the grievant except to the extent that the grievant may
pursue other remedies under applicable state and federal law, including the
grievant's right to appeal to the superintendent for a
hearing.
(1) This
requirement that the decision is binding shall not preclude the health care
insurer from making payment on the claim or otherwise providing benefits at any
time, including after an IRO's decision or following an external review by the
superintendent that denies the claim or otherwise fails to require such payment
or benefits.
(2) Upon receipt of a
decision by an IRO reversing an adverse determination, the health care insurer
shall approve coverage for the health care service for which the IRO review was
conducted, subject to any applicable co-payment, co-insurance and deductible
amounts for which the grievant is responsible without delay, regardless of
whether the health care insurer intends to seek judicial review of the external
review decision and unless or until there is a final judicial decision
otherwise.
