Section 420-J:5-d Certification of Independent Review Organizations.
I. The certification of independent review organizations shall be conducted as follows:
(a) The commissioner shall certify independent review organizations eligible to be selected to conduct external reviews under this section to ensure that an independent review organization satisfies the minimum qualifications established under paragraph II.
(b) The commissioner shall develop an application form for initially certifying and recertifying independent review organizations to conduct external reviews.
(c) Independent review organizations wishing to be certified shall submit the application form and include all documentation and information necessary for the commissioner to determine whether the independent review organization satisfies the minimum qualifications established under paragraph II.
(d) The commissioner may determine that accreditation by a nationally recognized private accrediting entity with established and maintained standards for independent review organizations that meet or exceed the minimum qualifications established under paragraph II is sufficient for certification under this paragraph.
(e) The commissioner shall maintain and periodically update a list of certified independent review organizations.
(f) Whenever the commissioner determines that an independent review organization no longer satisfies the minimum qualifications established under paragraph II, the commissioner shall terminate the certification of the independent review organization and remove it from the list of certified independent review organizations that is maintained by the commissioner pursuant to subparagraph I(e).
II. To be certified under paragraph I to conduct external reviews, an independent review organization shall meet the following minimum qualifications:
(a) It shall develop and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process.
(b) It shall establish and maintain a quality assurance program that:
(1) Ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner;
(2) Ensures the selection of qualified and impartial clinical peer reviewers to conduct external reviews on behalf of the independent review organization with suitable matching of reviewers to specific cases;
(3) Ensures the confidentiality of medical and treatment records; and
(4) Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this section.
(c) It shall agree to maintain and provide to the commissioner such information as may be required to fulfill the provisions and purposes of this section.
(d) It shall assign clinical peer reviewers to conduct external reviews who are physicians or other appropriate health care providers and who:
(1) Are experts in the treatment of the covered person's medical condition that is the subject of the external review;
(2) Are knowledgeable about the recommended health care service or treatment through actual clinical experience;
(3) Hold a non-restricted license in a state of the United States and, for physicians, a current certification by a specialty board recognized by the American Board of Medical Specialties in the area or areas appropriate to the subject of the external review;
(4) Have no history of disciplinary actions or sanctions that have been taken or are pending by any hospital, governmental agency, or regulatory body; and
(5) Have agreed to disclose any potential conflict of interest.
(e) It shall be free of any conflict of interest. To meet this qualification, an independent review organization may not own or control or in any way be owned or controlled by a health carrier, a national, state, or local trade association of health carriers, or a national, state, or local trade association of health care providers. In addition, in order to qualify to conduct an external review of a specific case, neither the independent review organization selected to conduct the external review nor any clinical peer reviewer assigned by the independent organization to conduct the external review may have a material professional, familial or financial interest in any of the following:
(1) The health carrier that is the subject of the external review;
(2) Any officer, director, or management employee of the health carrier 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 or institution 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; or
(6) The covered person or the covered person's authorized representative.
(f) Its charges for services provided shall be competitive and reasonable.
(g) For the purpose of allowing in-state health care providers to act as clinical peer reviewers in the conduct of external reviews, the commissioner may determine, in specific cases, that an affiliation with a hospital, an institution, an academic medical center, or a health carrier provider network does not in and of itself constitute a conflict of interest which is sufficient to preclude that provider from acting as a clinical peer reviewer, so long as the affiliation is disclosed to the covered person or the covered person's authorized representative.
(h) The following organizations shall not be eligible for certification to conduct external reviews:
(1) Professional or trade associations of health care providers;
(2) Subsidiaries or affiliates of such provider associations;
(3) Health carrier or health plan associations; and
(4) Subsidiaries or affiliates of health plan or health carrier associations.
Source. 2000, 18:13, eff. Sept. 3, 2000.