RS 22:1137 Minimum qualifications for independent review organizations
§1137. Minimum qualifications for independent review organizations
A. To qualify to conduct external reviews for an MNRO, an independent review organization shall meet the following minimum qualifications:
(1) Develop written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process that include, at a minimum, the following:
(a) Procedures to ensure that external reviews are conducted within the specified time frames and that required notices are provided in a timely manner.
(b) Procedures to ensure the selection of qualified and impartial clinical peer reviewers to conduct external reviews on behalf of the independent review organization and suitable matching of reviewers to specific cases.
(c) Procedures to ensure the confidentiality of medical and treatment records and clinical review criteria.
(d) Procedures to ensure that any individual employed by or under contract with the independent review organization adheres to the requirements of this Subpart.
(2) Establish a quality assurance program.
(3) Establish a toll-free telephone service to receive information related to external reviews on a twenty-four-hour-day, seven-day-a-week basis that is capable of accepting, recording, or providing appropriate instruction to incoming telephone callers during other than normal business hours.
B. Any clinical peer reviewer assigned by an independent review organization to conduct external reviews shall be a physician or other appropriate health care provider who meets the following minimum qualifications:
(1) Be an expert in the treatment of the covered person's medical condition that is the subject of the external review.
(2) Be knowledgeable about the recommended health care service or treatment through actual clinical experience that may be based on either of the following:
(a) The period of time spent actually treating patients with the same or similar medical condition of the covered person.
(b) The period of time that has elapsed between the clinical experience and the present.
(3) Hold a nonrestricted license in a state of the United States and, in the case of a physician, hold a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review.
(4) 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 a substantial question as to the clinical peer reviewer's physical, mental, or professional competence or moral character.
C. In addition to the requirements of Subsection A of this Section, an independent review organization shall not own or control, be a subsidiary of, in any way be owned or controlled by, or exercise control with a health insurance issuer, health benefit plan, a national, state, or local trade association of health benefit plans, or a national, state, or local trade association of health care providers.
D. In addition to the other requirements of this Section, in order to qualify to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor the clinical peer reviewer assigned by the independent organization to conduct the external review shall have a material professional, familial, or financial interest with any of the following:
(1) The MNRO that is the subject of the external review.
(2) Any officer, director, or management employee of the MNRO that is the subject of the external review.
(3) The health care provider or the health care provider's medical group or independent practice association recommending the health care service or treatment that is the subject of the external review.
(4) The facility at which the recommended health care service or treatment would be provided.
(5) The developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose treatment is the subject of the external review.
Acts 1999, No. 401, §1, eff. Jan. 1, 2000; Redesignated from R.S. 22:3086 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
NOTE: See Acts 1999, No. 401, §2, regarding applicability.
NOTE: Former R.S. 22:1137 redesignated as R.S. 22:1547 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.